In Ricky Moten v AETNA Life Insurance Company, a case filed recently at the District court for the Southern District of Texas, the plaintiff Ricky Moten through his Texas disability lawyer alleged that the AETNA Life Insurance Company (AETNA Life) being both the funder and administrator of the plaintiff’s disability plan is working under an inherent Conflict of Interest and wrongfully denied the plaintiff’s claim for disability benefits.
The Facts of the Aetna Disability Claim Denial
The plaintiff Ricky Moten was working as a production supervisor for a company called Alloy Polymers. By virtue of his employment, the plaintiff was covered under a group disability benefit policy which was issued by AETNA Life who was also the administrator of the plan and had the sole discretion to grant or deny benefits to claimants of the plan.
The plaintiff was suffering from degenerative and traumatic injuries. And because of lumber disc deterioration, lower back pain, sciatica lumbago and hypertension, he stopped working on June 12th 2009. This was also the plaintiff’s date of disability. As a consequence of him becoming disabled, the plaintiff applied for short term disability (STD) benefits with AETNA Life under the plan. Initially, on June 20th 2009 AETNA Life approved the payment of STD benefits to the plaintiff.
The First ERISA Appeal
However, on August 20th 2009, through a letter sent to the plaintiff, AETNA Life informed the plaintiff that it was denying the plaintiff further payment of STD benefits. The letter also informed the plaintiff that he had 180 days for which to appeal AETNA Life’s decision. The plaintiff on August 24th 2009 requested AETNA Life for an administrative review of the denial of disability benefits. In support of his appeal, the plaintiff submitted additional medical information which showed that the plaintiff was totally disabled from performing his “own occupation” or “any other occupation” as defined in the plan.
The Second ERISA Appeal
On September 10th 2009, AETNA Life informed the plaintiff that it was reaffirming its initial decision to deny the plaintiff’s claim for disability benefits. The plaintiff on April 9th 2010 filed a second appeal to AETNA Life regarding its decision to deny the plaintiff’s claim for disability benefits. As in the first appeal, to support his second appeal, the plaintiff submitted additional medical information that he was and is totally disabled from performing his “own occupation” or “any other occupation” as defined in the plan.
The Final Denial
On October 13th 2010, AETNA Life issued its final denial of the plaintiff’s claim by discounting the opinions of the plaintiff’s attending physicians which documented the physical limitations which the plaintiff was suffering from and their effects on the plaintiff’s ability to engage in work activities. As a result of AETNA Life’s final denial, the plaintiff exhausted all his administrative remedies and had no choice but to seek relief through the Court.
Aetna disability Lawsuit filed by the Plaintiff
In the action filed against AETNA Life, the plaintiff contended that AETNA Life had wrongfully denied the plaintiff’s claim for disability benefits and was in violation of both the plan and the Employee Retirement Income Security Act (ERISA) provisions because:
- The plaintiff was totally disabled and cannot perform the material duties of his own occupation or any other occupation which his medical condition, education, training or experience would allow him.
- AETENA Life failed to properly consider the evidence in the administrative records that the plaintiff was totally disabled.
- AETENA Life’s interpretation of “disability” in the plan was contrary to the plain language of the plan. As such, it was acting unreasonably, arbitrarily and capriciously.
- AETNA Life had violated its contractual obligations by failing to pay disability benefits to the plaintiff for which he was entitled to.
Therefore, the plaintiff is seeking from the Court:
- Declaratory and injunctive relief finding that the plaintiff is entitled to all past due short term and long term disability benefits and also future disability benefits unpaid under the terms of the plan
- Order AETNA Life to pay all past due short term and long term disability benefits and also future disability benefits according to the terms of the plan
- The award of reasonable attorney fees and cost
- Any other relief which the Court deem just and proper
Although AETNA Life being administrator and funder of a benefit plan may operate under a conflict of interest and which the court will take into consideration “as a factor determining whether there [was] an abuse of discretion”, it should be noted that it was ruled in MetLife v. Glenn that this is just “one factor among many” used by the Court for reviewing a claim’s denial decision.