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New Jersey Federal Court Rules Against Aetna and in Favor of Systems Analyst Disabled by Degenerative Joint Disease of the Lumbar Spine

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Before degenerative joint disease of the lumbar spine forced Christopher Patterson to leave his career, Mr. Patterson worked as a Systems Analyst for a consulting firm. Mr. Patterson’s employer provided long-term disability insurance through a plan administered by Aetna Life Insurance Company.

In 2001, Mr. Patterson’s back pain forced him to have lumbar surgery, after which he returned to work full-time and without restrictions. In 2006, his back pain once again returned and forced him to stop working. In early 2007, Mr. Patterson once again underwent yet another lumbar reconstruction surgery. Unfortunately, neither the first nor the second surgery proved to be the solution to Mr. Patterson’s chronic back pain and he was forced to apply for short-term and then long-term disability, which were both approved. Soon after Aetna approved his claims, he applied for social security disability, which the Social Security Administration promptly approved at the application stage and without the need for an administrative hearing.

In 2008, Aetna hired a private investigator to conduct video surveillance of Mr. Patterson. Aetna did not appear concerned with any of the surveillance since they continued paying his claim without interruption. In 2009, Aetna, again decided that it needed to conduct more video surveillance of Mr. Patterson and hired its private investigator to follow and video record Mr. Patterson’s activities over the course of several days.

The surveillance captured Mr. Patterson walking outside of his residence, gathering mail, bending at the waist, putting fluids into his truck, kneeling to check something in his vehicle, driving and twirling his cane as he walked. Four months later, Aetna again conducted more video surveillance which observed Mr. Patterson performing similar activity as the previous rounds of surveillance.

Aetna then sent Mr. Patterson for an “Independent Medical Examination” (IME) with Dr. Salvador Baylen. After reviewing the surveillance video, reviewing the medical history and examining Mr. Patterson, Dr. Baylen determined that Mr. Patterson was capable of performing sedentary work for 40 hours per week. He also opined that “after some degree of conditioning or work hardening, Mr. Patterson [would be] able to perform light duty physical work for 40 hours per week.

Following the video surveillance and IME, Aetna determined that Mr. Patterson remained totally disabled with “no ability to work” and continued approving his claim.

After 7 Years of Long-term Disability Benefits Aetna Terminates Chris Patterson’s Long-term Disability Claim

For the next five years, Aetna continued paying Mr. Patterson’s disability claim, however, again conducted yet more video surveillance in 2013, an internal medical review by a nurse consultant in 2014 and finally a vocational review in late 2014. Following the medical and vocational reviews Aetna decided it was time to terminate Mr. Patterson’s long-term disability and ceased paying benefits.

Following the submission of his mandatory administrative appeal, Aetna requested a second independent medical peer review. The orthopedic surgeon hired by Aetna to conduct the review opined that Mr. Patterson had the functional ability to sit without limitation, and walk for forty-five minutes at a time, but that he should avoid bending, twisting, or crawling, despite never physically examining Mr. Patterson. Following the medical review, Aetna informed Mr. Patterson that its decision to terminate his disability claim would be upheld on the basis that it felt he was capable of performing the material duties of his own occupation as defined in the national economy.

Federal Judge Finds Aetna’s Decision to Terminate Mr. Patterson’s Long-term Disability Claim Arbitrary and Capricious and Overturns Aetna’s Decision.

Following the exhaustion of his administrative appeals, Mr. Patterson filed a lawsuit against Aetna in the U.S. District Court for the District of New Jersey alleging that Aetna had improperly terminated his claim and sought reinstatement of his disability benefits, on-going waiver of his life insurance premiums, interest, court costs and attorney fees.

Following its review of the administrative record and the motions for summary judgment filed by Mr. Patterson and Aetna, the Court found that by not considering the actual duties performed by Mr. Patterson before he became disabled, and instead applying a broader national economy standard, which was not contained in the policy, it had acted arbitrarily and capriciously.

Furthermore, the Court was disturbed with Aetna’s inconsistent handling of Mr. Patterson’s long-term disability claim. Specifically, that:

After conducting its first and only independent medical examination conducted in April 2009, and undertaking surveillance, Aetna continued to find that plaintiff was disabled. Its own records say so: Patterson “cannot work” and the medical information “continues to support [Patterson’s] disability.” Yet the doctor who performed the IME in 2009, like the doctor who undertook the review of medical records in 2014, both found that Patterson was capable of “sedentary work.” AR 00180, 00823. So what changed in those five years…? Why was Patterson “disabled” in 2009 but not disabled in 2014 based on very similar evidence?

Following its review of the record the Court determined that Aetna’s termination of benefits was “unlawful, and as such, “benefits should be reinstated to restore the status quo.” The Court also allowed Mr. Patterson to submit an application for attorney fees pursuant to ERISA.

This case was not handled by our law firm, but it is instructive for any disability policy holder that has been denied benefits. For a Free Consultation, please contact Attorneys Dell & Schaefer.