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Aetna Reinstates Short and Long Term Disability Benefits on Appeal to Warehouse Manager Suffering from Major Depression

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

Prior to filing for disability benefits our client was in charge for the day to day operations of a large warehouse; responsible for inventory, shipments, deliveries, compliance and supervision of all employees within the warehouse. If this wasn’t enough he was responsible for these duties for all three work shifts. During the course of his employment he was stricken with cancer, and although he was “cured” his physical and emotional health would continue to suffer. Despite his efforts to return to work, he continued to suffer from ongoing fatigue and cognitive difficulties. Before too long his mental health had decompensated to the point that he was afraid to leave his house, was highly suspicious of others, incredibly anxious, and unable to maintain normal social relationships or interact with others. Unable to get out of bed or leave his home due to his escalating depression and panic attacks, he filed for disability benefits with Aetna.

Short Term Disability

Our client’s claim for short term disability benefits with Aetna was initially approved. For a period of the benefit term it seemed as if Aetna was not going to contest or challenge the sufficiency of the medical information provided by his psychiatrist and psychologist. However, as the remaining timeframe for short term disability benefits began to dwindle, Aetna increased the level of scrutiny on his claim. With only a couple weeks of short term disability benefits left, Aetna terminated our clients claim, and in doing so would effectively deny his claim for long term disability benefits on account of it.

Long Term Disability

Prior to the denial of short term disability benefits, our client submitted claim forms to begin a review for his entitlement to long term disability benefits under his employer’s policy. However, due to the fact his long term disability benefits were contingent upon him being disabled throughout the Elimination Period, which coincided with his claim for short term disability benefits, and his claim was denied for the remainder of his short term disability benefit, the long term disability claim followed suit and denied his claim for not satisfying the Elimination Period.

The Appeals

Following the receipt of two denial letters, our client contacted Attorneys Dell & Schaefer and consulted with Attorney Stephen Jessup. Following review of our client’s short and long term disability policies and the denial letters Attorney Jessup explained that the “type” of denial our client experienced was not uncommon. Specifically, Attorney Jessup noted that the short term disability policy was funded by the employer, which meant Aetna was not paying the monthly benefit. However, the long term disability policy was funded through the assets of Aetna, and with that came a financial incentive to deny the claim. By denying the short term disability benefit, Aetna had an easy road to deny long term disability benefits, and more importantly save money.

Attorney Jessup set to get complete copies of both the STD and LTD claim files. Review of same indicated that there was a disconnect in the sharing of information between the short and long term disability departments. What was even clearer was the fact that Aetna was discounting and ignoring the opinions of our client’s mental health providers and instead focusing on what it deemed to be a lack of clinical evidence. Armed with the reports of Aetna’s reviewing doctors, Attorney Jessup drafted specific questionnaires for our client’s treatment providers to complete in an effort to better document our client’s restrictions and limitations. Upon receipt of all updated medical information and additional support of disability, Attorney Jessup filed appeals to the short and long term denials.

The Approval

Despite an overwhelming amount of support that indicated our client could not perform the duties of his occupation, Aetna did not reach a decision on the appeal within the first 45 days and pursuant to ERISA requested an extension of 45 days. During the extension period, benefits for short term disability benefits were approved. However, it was still some time before Aetna made a decision on benefits for long term disability benefits. As the deadline to render a decision loomed, Aetna issued an initial approval of long term disability benefits for a limited period of time, and then denied future benefits. Normally this would prompt the right to another appeal; however, Aetna informed our client his only option was to bring civil action under ERISA. Acting swiftly, Attorney Jessup filed suit in Federal Court. In the interim, Aetna failed to provide the long term disability benefits for the period they initially approved. Attorney Jessup and his staff continually contacted Aetna to inquire as to the status of these benefits. It was during these communications that Aetna re-evaluated the appeal decision and advised Attorney Jessup that it was in fact approving our client’s claim for continued benefits without the need for additional legal action.

To What End…

…will an insurance company make you fight for your benefits? In this case – repeatedly in the hope that you will give up on the benefits you are entitled to and walk away. If your claim is being contested or challenged by your insurance carrier, please do not hesitate to contact Attorneys Dell & Schaefer at 1-800-828-7583 for a free consultation to determine how we may be able to assist you.