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Court Orders Aetna to Reinstate Long Term Disability Benefits

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.

In January 2011, when the definition of disability changed, Aetna still approved her claim for long term benefits agreeing she could not work at “any reasonable occupation” as defined by the plan. Aetna subsequently commissioned an independent review of West’s medical records and required her to submit to an independent medical exam (IME). Based on these reports, Aetna terminated her benefits in May 2013 and West appealed.

On appeal, West provided reports of numerous treating physicians who all opined she was disabled. Aetna upheld its denial of benefits based on the opinion of two of its doctors who reviewed some of her medical records and reported she was not disabled. After exhausting her administrative remedies, she filed this ERISA lawsuit.

Court Agrees with Plaintiff’s First Argument, so Does Not Consider Other Issues

In the lawsuit, Plaintiff raised several issues. The primary one was that “Aetna ignored evidence pointing to disability, including the opinions of her treating physicians, and ignored its own conclusion that she was disabled for the preceding four years.” Since the Court agreed “with Ms. West that Aetna’s decision was arbitrary and capricious based on its failure to account for substantial evidence of disability,” it did not consider her other arguments.

Plan Administrators Cannot Ignore Relevant Evidence That Is Not Refuted by Other Evidence in the Record

Although plan administrators are not required to give special weight to the opinions of treating physicians, they cannot ignore relevant evidence “that is not refuted by other evidence in the record.” Here, Aetna relied on the evidence presented by a reviewing physician who opined West was not disabled, and ignored numerous reports of treating physicians who all agreed West was permanently disabled.

Aetna also ignored objective evidence that West had suffered a brain injury which caused her to be functionally impaired and disabled. Aetna’s reviewing physician, who had no expertise in neurology, opined her test results were normal when her treating physician, who was board certified in neurology and neurophysiology, cited the test results as “objective evidence of her traumatic brain injury.” The plan administrator simply ignored the supporting evidence and gave no explanation as to why she rejected it.

The Court concluded that “the evidence in the record clearly demonstrates that Ms. West is entitled to benefits.” It ordered Aetna “to pay back-due benefits plus interest and to reinstate her benefits.” The Court also determined West was entitled to “reasonable attorneys’ fees and costs.”

This case was not handled by our office, but we believe it can be instructive to those who may have had long term disability benefits terminated even though there is substantial evidence supporting their claim.

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