California Federal Judge Finds Aetna Wrongly Denied Claimant’s Long-term Disability Benefits But Properly Denied Their Waiver of Life Insurance Premium

The U.S. District Court for the Central District of California recently ruled that a claimant, diagnosed with relapsing remitting multiple sclerosis and insured under Aetna long-term disability and life insurance policies, qualified for benefits under the long-term disability insurance policy but did not qualify for waiver of premium benefits under the life insurance policy.

Aetna Denies Long-term Disability Benefits to Insured Diagnosed with Multiple Sclerosis

Margueritte, a former bank relationship manager, began experiencing symptoms of multiple sclerosis in 2001. In 2011 and 2012 her symptoms appeared to progress. On one occasion, while accompanying clients to a car museum, she collapsed. Several months later she again fell after a business lunch with a supervisor. At this point she decided to take some time off work. Her treating physicians, which included a board certified neurologist, ordered an MRI to assess the status of her MS. The MRI showed evidence of demyelinating disease. Her physicians noted the changes evidenced by the MRI as well as her relayed complaints of episodic numbness in her right hand and generalized fatigue.

A few weeks later, Margueritte’s neurologist wrote a note allowing her to resume work. After returning to work several stress factors and incidents triggered her symptoms and sunk her into depression. In April 2012, approximately one month after returning to work Margueritte took an official leave of absence. Margueritte went in and out of work from April 2012 to February 2013, when she filed her disability claim with Aetna.

Unfortunately, shortly following the submission of her claim, Aetna denied her long-term disability claim. Although it agreed that Margueritte suffered from remitting-relapsing multiple sclerosis, it reasoned that she could perform all of her physical activities and that she had no abnormal exam findings at her most recent medical appointments. Margueritte promptly retained an attorney to assist her in appealing Aetna’s denial of benefits.

As part of her appeal she visited with an independent medical examiner, also a board certified neurologist. The independent medical examiner determined that it was his perspective, based on his evaluation and review of the records that Margueritte was unable to work due to progressive neuromuscular symptoms, cognitive decline and worsening fatigue.

After the appeal was submitted, Aetna began its review and retained a medical professional, another board certified neurologist, to review the claim. Aetna’s medical consultant considered the IME’s report as being inconsistent with the opinions of her treating physician, who was more familiar with her condition. Margueritte’s treating physician had opined a report that she did not suffer any significant impairment in cognitive function and that her symptomatology was secondary to depressed mood.

Critical MRI Submitted Immediately Before Aetna Denies Appeal

Immediately before Aetna closed its appeal review, Margueritte supplied Aetna with an updated MRI. The MRI showed significant interval progression of the disease over the past four months and multiple new plaques in Margueritte’s brain. The radiologist who reviewed the MRI described a new plaque extending from the left posterior corona radiate into the posterior limb of the left internal capsule, which the radiologist “suspected to contribute to the patient’s new symptoms” (a “pronounced gait disturbance…. [and] right-sided leg weakness and numbness” over the past three weeks). The next day, Aetna denied her appeals for long-term disability and life insurance waiver of premium.

Court Finds that Claimant Was Disabled Under the Long-term Disability Policy From Date of Final MRI However Not Entitled to Benefits Under The Life Insurance Waiver of Premium.

After Margueritte’s long-term disability and life insurance waiver of premium appeals were denied, her attorney filed suit in California federal court to recover her benefits under both policies.

However, the policies did not share the same definition of total disability, thus making it possible to qualify under one and not the other.

In order to qualify for total disability benefits under the long-term disability policy, the insured must be unable to perform the substantial and material duties of their own occupation, while under the life insurance policy, in order to qualify for waiver of premium, the insured must show that they are unable to perform not only their own occupation, but any gainful occupation for which they qualify based on education, training and experience.

The Court came to an interesting conclusion concerning Margueritte’s claims for benefits. It agreed with Aetna that for at least the period prior to the submission of the final MRI, there was insufficient evidence that her MS prevented her from performing the physical demands of her job. It also found that her treating physician’s opinions were credible and should carry weight, despite being unfavorable to her claim for the period of time preceding the final MRI.

However, following the submission of the final MRI report, unlike most of her prior diagnoses, which had observed moderate demyelination and mild symptomology, this report provided evidence of significant impairment – at least severe enough to disable her from her own occupation from the date of submission of the final MRI. The Court also found that there was a “strong correlation between degeneration revealed through neuroimaging and cognitive difficulty”.

Because the Aetna life insurance policy imposed a more stringent any gainful occupation standard, the Court found that there was insufficient evidence that Margueritte qualified for the waiver benefit.

The Court’s found in favor of Aetna for the 12 months preceding Margueritte’s final MRI and on the issue of the life insurance waiver of premium, but awarded her benefits from the date of the final MRI forward.