Articles Posted in Aetna Disability Claim

In a recent case out of Massachusetts, a Court sided with a disabled claimant and found that Aetna’s decision to deny the claim for benefits was wrong. Aetna justified its denial as it believed the disabling medical condition to be a “pre-existing” condition and the policy governing this claim, like most Long Term Disability (“LTD”) policies, contained a provision that states that benefits will not be paid for pre-existing conditions that cause someone to be disabled during their first year of coverage. Specifically, the policy stated that “a disease or injury is a pre-existing condition if, during the 3 months before the date you last became covered: it was diagnosed or treated, or services were received for the disease or injury, or you took drugs or medicines prescribed or recommended by a physician for that condition.”
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In this case, a policyholder was diagnosed with an aggressive form of skin cancer and had to undergo treatments. Due to the date of his policy renewal and the date of his treatments, the policyholder did not expect there to be any issue regarding his eventual claim when he had to file for disability. The severity of his cancer and the invasiveness of his treatments made it so he was unable to work and had to make a claim on his disability insurance policy with Aetna.
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In this video, Attorneys Gregory Dell and Cesar Gavidia discuss a current case Mr. Gavidia is litigating in Federal court concerning Aetna’s initial granting, then denying, long term disability benefits to a software engineer who suffered a stroke in 2011. He later returned to work, but after about three years, he started having issues with cognitive, visual, auditory, spatial, and perceptual functioning that interfered with his ability to do his job, so he filed a claim for long-term disability benefits with Aetna Insurance Company.

To support his claim, the engineer submitted his medical records from his neuropsychologist and reports of cognitive testing. Aetna’s own medical professionals agreed with the reports, so Aetna approved his claim. About 18 months later, benefits were terminated. As a basis for its denial of any further disability benefits, Aetna relied somewhat on the claimant’s social media postings that indicated to Aetna that the man was not disabled. Aetna also denied his administrative appeal.

That is when Mr. Gavidia became involved in the case and filed an ERISA lawsuit in Federal court. The main litigation issues are: 1) The policy appears to only require claimants to be disabled from their own occupation, but denial letters say he must be disabled from any occupation; 2) Aetna chose an incorrect specialist to examine and review the records. It should have chosen a neuropsychologist; 3) Aetna’s neurologist only spent about 30 minutes with the claimant, conducted only a screening test, and did not review raw data from the claimant’s treating physician’s neuropsychological testing.

In Sarah G. Gorena v. Aenta Life Insurance Company, Plaintiff was employed for 10 years as a staff analyst for Boeing when she sought disability benefits solely due to her diagnosis of multiple sclerosis (MS), although she had a number of other health issues. After being awarded several periods of short-term disability, in July 2015, she made a claim for long-term disability benefits (LTD). Her claim was denied, as was her administrative appeal. After exhausting her administrative remedies, she filed this ERISA lawsuit.
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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.
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In Marie West v. Aetna Life Insurance Company, Plaintiff West, a contract administrator at Ciber Inc., fell down some stairs on October 22, 2007. She fractured her spine and suffered a traumatic brain injury (TBI). Although she continued working for a time, by June 2008, she had to undergo a spinal fusion. After attempting unsuccessfully to return to work, she required a second spinal fusion. She was still unable to work due to continuous debilitating pain. Finally, in July 2009, her claim for long term disability was approved based on a finding that she was unable to work in her own occupation.
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Roy Neil Johnston, M.D. v. Aetna Life Insurance Company involves the scope of permissible discovery in an ERISA lawsuit brought when an insurer terminates a claimant’s short-term disability benefits and denies him long-term disability benefits. Aetna initially found Johnston disabled based on the opinion of its own independent neurologist. Apparently, Aetna’s medical review found Johnston to be disabled, but it denied disability benefits based on a surveillance video.
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The Ninth Circuit ruled that if the internal deadline for a long-term disability claimant to file an administrative appeal falls on a Saturday, Sunday or holiday, the deadline is extended to the next day that is not a Saturday, Sunday or holiday.
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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.
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Richard R. and his Illinois disability attorney filed a lawsuit in Federal Court in Illinois on December 9, 2010 against his employer and AETNA Life Insurance Company for long term disability benefits. A Weston Engineering Inc. employee since July 6, 2009, Richard R., a headache sufferer since he was a teenager, complained to his family doctor of intensification of his headache problems. Consequently, Richard R.’s doctor increased Richard R.’s pain medication to try to remedy the situation.
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