Florida court finds Aetna’s denial of long term disability benefits was supported by the medical record which showed plaintiff could work in a sedentary job.
Mercado v. Federal Express Corporation and Aetna Life Insurance Company is a case where a federal Florida district court sided with Aetna after evaluating Aetna’s decision to deny plaintiff Mercado’s application for long term disability benefits. Armando Mercado was an Operations Manager at FedEx when he quit working due to multiple medical problems including: “Avascular necrosis in in his hips, back pain, spinal stenosis, obstructive sleep apnea, and gastroesophageal reflux disease. He also underwent surgeries on his ankles and elbow, used a machine for his sleep apnea, and suffered from polyneuropathy in his lower extremities.”
Aetna awarded Mercado two years of disability benefits based on his inability to work in his own occupation. After two years, the definition of disability changed and Mercado was required to prove he was disabled from working at any occupation. Near the end of the two-year “own occupation” period, Aetna ordered a peer review of Mercado’s medical records. The reviewer determined Mercado could work at a sedentary position, so Aetna informed him his benefits would be terminated at the end of the two-year period. Plaintiff appealed and Aetna requested a second peer review, which agreed with the first one, so Aetna stuck with its decision to terminate benefits. Mercado then filed this ERISA lawsuit. The court upheld Aetna’s denial on several grounds.
Aetna Was Not Bound by the Social Security Administration’s Finding of Disability
The Social Security Administration (SSA) granted Mercado’s application for disability and Mercado argued that Aetna did not properly consider that in its denial of his claim. The Florida court noted that a court is not bound by disability decisions made by the SSA. In this case, Aetna’s requirements were more stringent than the SSA’s. In addition, although Mercado disagreed with the way in which Aetna interpreted the SSA’s findings, the court held that since Aetna’s interpretation was a reasonable one, it’s decision to terminate benefits was not arbitrary and capricious.
Aetna Was Not Bound by Opinions of the VA
The VA, in a compensation and pension review, found Mercado unable to work, even in a sedentary position. Aetna discounted this report, made as a result of a November 2013 exam. Aetna interpreted the report differently than did Mercado. Reviewing physicians are not required to provide any special deference to the opinions of treating physicians. But, Aetna’s reviewing physician specifically stated why the opinion was not given much weight, plus Mercado’s physical condition substantially improved after the date of the report, so it was reasonable for Aetna not to consider it.
Aetna Properly Relied on Peer Review Reports
Mercado objected to Aetna’s use of peer review reports instead of the reports of his treating physician. The court noted, “it was Aetna’s prerogative to consult and appraise the findings of treating and independent physicians alike. It is also not arbitrary or capricious for Aetna to use, like here, “file” reviews by independent doctors as opposed to live examinations.” Aetna’s explanation of all the information it had considered, including the reports of treating physicians as well as the peer review reports was reasonable and not arbitrary and capricious.
This case was not handled by our firm, but we think it can be instructive for those fighting for long term disability benefits on the grounds that they are precluded from working in any occupation. If you have any questions about this case, or any issue concerning your disability coverage, contact one of our attorneys for a free consultation.