Aetna’s Denial of Disability Benefits Was Arbitrary and Capricious

In Mark v. Aetna Life Insurance Company and FedEx Office and Print Services, Inc., Plaintiff Julia Mark, an employee of FedEx Office, injured her neck, back, ankle, and left knee when she fell on a sidewalk. Her left knee continued to cause her pain. She filed a claim for short term disability benefits (STD) with Aetna, the disability Plan Administrator to whom FedEx had delegated authority to interpret the plan.

Aetna initially agreed that Mark was disabled because of her injured knee and could not perform her job as a production specialist. Her job duties required her to stand for her entire shift, move and lift up to 55 pounds, and to constantly bend and twist at the waist and knees. But, approximately two-and-a-half months after awarding her STDs, Aetna terminated them, informing her there were insufficient clinical findings to support her claim for STD benefits.

Mark appealed and provided more medical records. Aetna denied her appeal, stating “there are no significant objective findings to substantiate a functional impairment.” Since she had exhausted her administrative remedies, she filed this ERISA lawsuit.

The Colorado Magistrate Judge conducted a comprehensive review of case law and Mark’s medical records. He determined that Aetna acted arbitrarily and capriciously in terminating her benefits. He recommended that the District Court Judge remand the case to Aetna with instructions to “fully consider the entire record and to request and obtain additional documentation if necessary to determine Mark’s eligibility for short term disability benefits…”

Aetna Erred in Not Requesting More Information from Mark’s Treating Physician or Requesting an Independent Medical Exam (IME)

Mark’s treating physician, Dr. Chang, indicated Mark’s condition was improving, yet his work restrictions remained the same. The Plan Administrator repeatedly informed Chang that Aetna needed “diagnostic test results.” But, if Chang ever performed any diagnostic tests, he did not provide Aetna the results. Because of this, his opinion was disregarded by Aetna’s reviewing physician, Dr. Andrews.

The Magistrate Judge believed that Mark had done her best to cooperate with Aetna. He put the onus on Chang and Aetna. He said that Aetna “knew or should have known” that Chang “dropped the ball.” Aetna had the ability to request an IME which could have provided it the information it was seeking, but not getting, from Chang.

The Magistrate concluded, “Given the obvious deficiencies of Dr. Andrew’s record review concerning Mark’s objective condition, coupled with Dr. Chang’s inexplicable inability to gather clinical data, an independent medical exam was warranted. Aetna’s failure to conduct one, under these circumstances, was arbitrary and capricious.”

Aetna Failed to Analyze Results of Functional Movement Screens

Functional movement screens were performed by Mark’s physical therapist. These test results convinced the court that Mark was unable to perform her job duties. Aetna failed to analyze this information and argued that the tests offered no context for how the results impaired Mark and kept her from performing her job duties. The Magistrate concluded that the failure of Aetna to ask for “additional or clarifying information” was arbitrary and capricious.

This case was not handled by our office, but we believe it can be helpful for those preparing their claims for STD benefits. For help with STD or long term disability benefits, contact one of our attorneys at Dell & Schaefer for a free consultation.