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.
The District Court for the Western District of Washington found the weight of the evidence supported Plaintiff’s claim. It ordered Aetna to provide LTD benefits to her for the maximum benefit duration, finding her disabled from working in both her own occupation or any other “reasonable occupation.”
Aetna “Cherry-Picked” Records to Find Evidence Supporting its Denial and Ignored Evidence Supporting Plaintiff’s Claim
The Court noted that Plaintiff’s long-time treating physician, Dr. Reif, was a well-respected MS researcher who had studied MS for more than 20 years. She instructed other medical professionals on the topic as well as performing disability/employability examinations.
Evidence presented by Plaintiff to support her claim included:
- A letter from Dr. Reif, who treated Plaintiff since 2007, she determined that Plaintiff was permanently disabled.
- At least eight years of Dr. Reif’s medical records and letters.
- 10 MRI reports documenting progressive MS.
- 14 psychological reports noting that Gorena suffered from depression, but the depression was caused by her MS.
- 16 APS forms.
- An FCE report showing cognitive dysfunction and balance issues as well as optic neuritis in Plaintiff’s left eye.
Medical reports documented Plaintiff suffered from incontinence, occasionally lost control of her bowels, had sensory loss and weakness in some muscles, all of which made it impossible for her to function in her job as a systems analyst. Instead of acknowledging any of these disabilities as ones that would interfere with the performance of her job, Aetna seemed to go through the records carefully finding any statement that could be used to justify denying LTD benefits.
A nurse, whose qualifications were not in evidence, reviewed Dr. Reif’s records. The nurse’s conclusion inclined the court to believe that he did not “closely read” Dr. Reif’s documentation and conclusions regarding Plaintiff’s condition.” The FCE was not even mentioned by any Aetna medical reviewer. One Aetna reviewer acknowledged that “while bowel accidents and incontinence were a ‘nuisance,’ they did not represent functional incapacity” and should not interfere with her ability to work full time.
The Court found examples of Aetna’s approach to “cherry-pick statements out of context” were numerous. Aetna’s review was “outcome-driven… made at the expense of the overwhelming weight of the evidence to the contrary,” and “It is the considered opinion of this Court that the company’s conduct falls well below the statutory standard for their fiduciary duty.”
Court Rules in Favor of Plaintiff
The Court ruled that Plaintiff had proven her case and “established beyond question the lifelong and steadily deteriorating nature of her medical condition.” She was entitled to LTD benefits as disabled under the Plan definition of her own occupation as well as the “any reasonable occupation” section of the Plan.
This case was not handled by our firm, but we believe it can be instructive to those presenting overwhelming evidence to support their claims for LTD benefits, but who are still being denied benefits by their insurers. For any question about disability benefits, contact us at Dell & Schaefer for a free consultation.