An Aetna disability policy holder suffering from a brain injury gets her denial overturned on appeal. Aetna claimed our client did not have post-concussive syndrome that’s affected their ability to work. After an appeal filed by Attorneys Dell & Schafer showed a few things that Aetna got wrong, her denial was reversed.
ATTORNEY ALEXANDER PALAMARA: Well, I’m Attorney Alexander Palamara of the law firm of Dell and Schaefer. And today I want to discuss a– kind of a happy case– a happy outcome of a case that we filed an appeal on, and I got a great outcome for our client.
Our client, prior to hiring us, worked at SAP America for seven years. She was a senior solution sales executive, high executive job, worked there for seven years, and made a very good living. Unfortunately, for her, in late 2016, she suffered a fall, and had a head injury, and had been diagnosed with a post-concussive syndrome, so she had a traumatic brain injury.
And she tried to return to work but, unfortunately, in early 2017, she was forced to stop working at her position. And she had to make a claim for disability insurance benefits. Unfortunately for her, her– actually, fortunate for her, her claim was initially approved by Aetna. And Aetna actually approved this claim, at first, in good faith.
They actually denied her claim saying, we don’t believe you have post-concussive syndrome that’s affecting your ability to work. But we believe you actually might have a psychological issue, a mental health issue that needs to be treated. Substantially approved her claim, allowing her time to get treatment for mental health disorder, what they believed was a mental health disorder.
And they approved her claim for a short period of time. Unfortunately, our client was not suffering from mental health disorder. So there is no additional records to submit. And after a few months on claim, Aetna ended up denying her claim. In support, I guess, in support of their reasoning for denying the claim, they said that her medical records were not supportive of TBI, obviously. They said her neuropsychological testing was inconsistent, and ended up denying her claim for those reasons.
Our client found us. And we ended up ordering all her medical documentation on the claim. And our review showed a few things that Aetna got wrong. First and foremost, the neuropsychological testing was not inconsistent at all. In fact, it’s true that she had a significant processing skills or processing speed was significantly reduced. She had a compromise in her functional memory skills, et cetera, et cetera.
Her neuropsychological evaluation was very supportive of her claim. Her treating physicians were also very supportive of her claim. So then we were going to draft an appeal. But the last thing we did before we filed the appeal with Aetna, we actually reached out to an independent physician reviewer.
This doctor actually worked for, in the past, the University of Virginia, was actually a doctor, a physician, for USA Swimming, USA Soccer, USA Women’s Soccer. He actually started the– or is part of the Brain Injury Alliance, so I knew that this expert would be the person to go to to review these documents. And if this person was supportive of my client’s claim, I knew there was no doubt that Aetna would have to overturn their denial.
Our doctor actually took a look at these records, and we spoke to him at length. We told them our client’s occupational requirements. We told him our client’s history. He looked at all the medical records. And he came to the conclusion that he would unequivocally support that our client is disabled from her previous occupation.
He wrote a great report for us, so we submitted a timely appeal with this report, as well as other medical records supporting our client’s claim, with argument as to why Aetna– why their decision was not only wrong, but it was arbitrary and capricious. And within six weeks of filing that appeal, Aetna overturned that denial.
Our client is back on claim, receiving benefits to this day. And she’ll likely need benefits till the age of 65. If she’s able to go back to work, she’s able to go back to work, but she knows that if she needs this claim, that Dell and Schaefer will do whatever it takes to keep her on claim. So if you have a similar claim where Aetna has denied your long-term disability insurance claim, please do not hesitate to contact us for a free phone call. We’ll gladly assist you any way we possibly can.