Denials of AETNA disability benefits are certainly not unusual, as many thousands of policyholders can confirm. However, if the denied disability claim eventually makes its way past an ERISA denial, an ERISA appeal, and into a court of law, the game can sometimes change in favor of the claimant. Disability insurance attorney Greg Dell and fellow lawyer Stephen Jessup tell a tale of when it did just that.
The disabled claimant was a former employee of Southwest Airlines and suffered an unfortunate back injury at work back in 2008. She continued to work until 2011, at which point she finally underwent surgery to address her back problem. During this time, according to Greg Dell, she also developed a hip issue that eventually led to a total hip replacement. So, she filed her claim for disability, based on her group disability policy with Aetna.
It’s no shock that Aetna eventually denied her claim. But in this particular case, which ended up in Illinois federal district court, the nuances and anomalies were enough for the court to ultimately rule in favor of the employee. Having a competent and skilled disability lawyer in a situation like this can be crucial since the intricacies of a long-term disability (LTD) are often open to interpretation.
What Did Aetna Do Wrong This Time?
Attorney Greg Dell admits that he loves talking about cases against Aetna in which the court basically “beats them up” and says, once again, that they were wrong in denying a claim. When asked how Aetna tried to “screw another claimant,” Stephen Jessup replies, “It’s the same song and dance.”
However, this time, the claimant was already receiving workers’ compensation payments, so Aetna was already given an offset on what they had to pay her. So, Aetna initially approved her claim under the “own occupation” criteria, which essentially means that the insurance company deemed her unable to perform her current occupation with Southwest Airlines.
The story doesn’t end there – far from it. Stephen Jessup notes that Aetna went on to hire Allsup, a company that helps people receive Social Security Disability benefits (SSDI). The SSDI benefits were approved relatively quickly, which meant that, between Worker’s Comp and Social Security, Aetna was getting a considerable reduction in the monthly benefit amount they had to pay. The insurance company was now down to paying the minimum of only $100 a month – which is practically no financial risk to them at this point.
Did they stop there? No. They bided their time until the case reached the 24-month mark, when it was going to enter the “any occupation” stage. This is the point at which issues really start to happen, as the insurance company evaluates to see if the policyholder is capable of working in any occupation, even one other than the job she was performing at the time of becoming disabled.
In this particular employee’s case, they did approve her beyond the initial 24 months. But as soon as the workers’ compensation ended, and they had to start paying her more, things abruptly changed.
“Lo and behold,” explains Stephen Jessup, “they had a review done by a nurse, and a vocational assessment that found a handful of jobs they felt she’d be capable of – and they denied her claim.”
It was a standard denial from Aetna, and no doctors were involved in that initial denial. Even when the claimant appealed, stating that her condition had not changed and that Social Security was still paying her disability claim, Aetna still didn’t send her for an independent medical evaluation. They instead hired some outside doctors to conduct reviews and render opinions that she would be able to do sedentary work.
Aetna also claimed, in their denial letters, that the doctors they hired had reached out to the claimant’s treating physician but did not receive a response, leaving them free to rely on their own doctor’s opinions.
When the case finally reached a lawsuit, according to Stephen Jessup, the insurance company was ready with its time-tested arguments to the court: we tried to contact her doctors, we had a vocational assessment done, and we gave her every chance to prove that she was still entitled to benefits. But this time, the court was ready with its own response.
The Court Stands Firm
In an unexpected twist, the court wasn’t having it. “The court really started to undermine and attack Aetna’s positions,” noted Stephen Jessup, “including all these very common things that they do in the vast majority of their claims.”
He goes on to explain the significant findings that the court ruled were unreasonable about this particular review by Aetna. First and foremost, a functional capacity evaluation (FCE) was part of the file – which happens a lot – and the overall results of the FCE did indeed indicate that she fell within the “light duty” range of ability. Aetna was running wild with this, according to Jessup – until the court made a much deeper analysis.
When the actual findings of the FCE came to light through further examination, it became apparent that the observations throughout the test were at not necessarily reflected in the final conclusion. The test indicated that the policyholder could only sit for an amount of time ranging between 2.5 to five hours, and the court rightfully argued that the standard for sedentary work had not been met. The claimant would have to be able to sit for at least six hours of a workday, meaning that Aetna had misinterpreted the findings of the FCE.
The next thing the court took issue with was the insurance company’s reliance on their own doctor’s opinions, which included no firsthand observations. They didn’t examine the insured disabled employee at all, and they judge also noted there was no indication of them even providing a full review of the case.
The judge came down hard on that, explains Stephen Jessup, along with the fact that the medical records showed no evidence of improvement. “There was nothing in the documentation to state that, after back surgery and hip replacement, all of a sudden she has this ability to work consistently.”
In addition, the claimant was still qualifying for Social Security disability (SSDI), which gave credibility to her claim. The court, in this decisive victory for the claimant, told Aetna to put her back on claim and to pay back all the benefits. One thing to note, however, is that this was a district court decision and therefore Aetna could appeal this decision – and they often do.
If that happens, according to Greg Dell, the sad thing is that the claimant would not get paid during the appeal, which could take another year or two before that decision comes out. It’s a vicious cycle in which the claimant can be, in total, three to four years down the road and receiving no benefits.
It tends to be part of the strategy of the disability insurance companies, notes Dell. “Let me bleed the claimant so that eventually they’ll maybe take a low settlement, or go away, or be forced to go back to work… they try to do something because they’ve got to put food on the table.”
Fortunately, firms like Dell & Schaefer are able to help people in these types of situations, and they are devoted to fighting for policyholders to get the benefits they are owed. Greg Dell encourages anyone with a denied claim by Aetna or any other long-term disability insurance company to call for a free initial consultation via telephone or to contact them through the website. They handle cases throughout the country.
Hartford acquired Aetna and you can read more about Hartford disability claims here: https://www.diattorney.com/hartford/.