• Attorney Tips for Hartford & Aetna Disability Denials, Appeals & LawsuitsAttorney Tips for Hartford & Aetna Disability Denials, Appeals & Lawsuits
  • Aetna Long Term Disability Claim Denial InformationAetna Long Term Disability Claim Denial Information
  • Is The Hartford Disability Purchase Of Aetna Bad For Aetna LTD Policy Holders?Is The Hartford Disability Purchase Of Aetna Bad For Aetna LTD Policy Holders?
  • Aetna LTD Denial Reversed for Failure to Address Medication Side EffectsAetna LTD Denial Reversed for Failure to Address Medication Side Effects
  • Aetna Disabilty Denial to Woman With MS Reversed Following ERISA AppealAetna Disabilty Denial to Woman With MS Reversed Following ERISA Appeal
  • Aetna Ordered To Pay Attorney Fees Following Denial of Disability BenefitsAetna Ordered To Pay Attorney Fees Following Denial of Disability Benefits
  • Aetna Disability Insurance Claims - A Disability Attorney's ViewAetna Disability Insurance Claims - A Disability Attorney's View
  • Aetna Long Term Disability Lump Sum Buyout or SettlementAetna Long Term Disability Lump Sum Buyout or Settlement
  • Important Steps to Take If Aetna Has Denied Your Disability Insurance BenefitsImportant Steps to Take If Aetna Has Denied Your Disability Insurance Benefits
  • Aetna Claim Denial Reversed After Aetna Disability Appeal SubmissionAetna Claim Denial Reversed After Aetna Disability Appeal Submission
  • Aetna Disability Insurance Denial of a Boeing Employee Results in BankruptcyAetna Disability Insurance Denial of a Boeing Employee Results in Bankruptcy
  • Aetna Insurance Denies Disability Benefits to Fed-EX Employee Approved for SSDI BenefitsAetna Insurance Denies Disability Benefits to Fed-EX Employee Approved for SSDI Benefits

A Judge’s 8 Reasons that Aetna Reasonably Denied Disability Benefits to Bank of America Employee

In Claire Refaey v. Aetna Life Insurance Company, in late September 2015, Plaintiff suffered from a viral disease causing quite a few medical symptoms including nausea, abdominal pain, diarrhea, weakness in her extremities, hypotension, and inability to walk. She was hospitalized and treated symptomatically. She was released from the hospital on October 2, 2015 and referred for outpatient psychiatric care.

On October 7, 2015, she was seen in an emergency room and admitted to the hospital due to weakness in her legs during a walk. She was released from the hospital two days later, on October 9, 2015.

Over the next few months, Plaintiff was seen by several physicians in different specialties including a cardiologist, neurologist, and primary care physician. She often complained about her legs being so weak she was unable to walk. Neuro-diagnostic testing was normal and the doctor who performed the test noted that she “exhibited significantly poor effort” during the examination.

During this time, her claim for short-term disability (STD) benefits was approved. Her treating physicians often recommended she get psychiatric care.

Finally, on April 26, 2016, a doctor at the Mayo Clinic diagnosed Plaintiff with chronic fatigue syndrome (CFS). From May 25, 2016 through June 17, 2016, she participated in a treatment regimen at Mayo. She did well with the exercise, group therapy, and occupational therapy sessions, but consistently complained about her job and said she did not want to return to it.

Plaintiff’s final diagnosis from Mayo Clinic included CFS and central sensitization syndrome (CSS) which includes the overlapping conditions of CFS, fibromyalgia, and myofascial pain. During the following months, she was treated by several physicians and participated in a study at the National Institutes of Health for her diagnosed conditions of CFS and CSS.

Plaintiff received STD benefits from September 28, 2015 until January 5, 2016 when Aetna terminated them. Litigation ensued and the case was settled and dismissed on January 15, 2018. On January 23, 2018, video surveillance showed Plaintiff outside of her home continuously for six hours. She drove, shopped, gassed up her car, talked on her cell phone, walked 0.2 miles with her young son, stood on the sidewalk for 13 minutes engaged in conversation, and used her computer while sitting upright after she returned home.

On February 8, 2018, Plaintiff’s disability insurance attorney filed a claim for long-term disability (LTD) benefits. She submitted her medical records and a personal statement about why she was incapable of working at any job.

Aetna found her personal statement was not supported by her medical records nor by its own video surveillance resulting in a disability insurance claim denial for LTD benefits on March 27, 2018. Plaintiff filed an administrative appeal which was denied on July 6, 2018. Plaintiff then filed this ERISA lawsuit in the U.S. District Court for the Western District of North Carolina.

On June 18, 2020, the District Court determined that Aetna did not abuse its discretion when it denied her LTD benefits. The Court made its ruling by analyzing eight factors presented in Booth v. Wal-Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335, 342–43 (4th Cir. 2000), the Fourth Circuit case which laid out the following eight nonexclusive factors to be considered in reviewing the reasonableness of an administrator’s decision:

(1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary’s interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decision making process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary’s motives and any conflict of interest it may have.

Application of the Booth Factors to Plaintiff’s Case

Factors 1 and 2: The language and purpose of the plan.

The language of the Plan makes it clear that a person is disabled if they are unable to perform the duties of their own occupation for the first 18 months. After that, the person must be unable to perform the duties of any reasonable occupation. The goal is to provide benefits to those who meet the disability definitions.

Aetna’s decision denying Plaintiff’s claim for LTD benefits and in denying her appeal of the denial was consistent with the Plan’s language and its purpose.

Booth Factor 3: Adequacy of materials considered to make the decision and the degree to which they support it.

Aetna fully considered the medical records and other materials submitted by Plaintiff in support of her claim. Aetna provided these materials to two peer reviewing physicians, both of whom confirmed they considered all the material and found the medical evidence did not support a functional impairment.

Plaintiff’s medical record includes information contrary to her claims. Those records, along with the contents of the video surveillance, provided sufficient evidence to refute her subjective reports. Plaintiff complained that the peer review physicians did not address some information in her medical records, but the Court said there is no requirement for a peer review physician to address every piece of medical information in a plaintiff’s record.

The Court concluded that analysis of this third Booth factor supported the finding that Aetna did not abuse its discretion in denying Plaintiff LTD benefits.

Booth Factor 4: Whether the fiduciary’s interpretation of the Plan is consistent with other provisions of the Plan and earlier interpretations of it.

The Court looked at this factor in detail and weighed this factor in favor of finding Aetna’s decision was reasonable.

Booth Factor 5: Whether the decision-making process was reasoned and principled.

Despite the medical records encompassing two years of numerous physicians in various specialties providing treatment and analysis, only one doctor ultimately supported her claim for LTD benefits based on the diagnosis of CFS. In fact, many physicians expressed skepticism of her claim to be disabled.

One treating physician specifically noted that “long term disability is not recommended.” Aetna had peer review of the medical records which supported its decision to deny LTD benefits.

The Court found that “Plaintiff’s own medical record and submissions, alone, constitute a reasonable basis for Aetna’s decision to deny her request for long-term disability benefits.”

Booth Factor 6: Whether the decision was consistent with the procedural and substantive requirements of ERISA.

ERISA requires the Plan to provide participants a full and fair hearing and to provide the participant, in writing, the reasons for the denial of benefits. Aetna did this and its actions were consistent with ERISA requirements.

Booth Factor 7: Was any external standard relevant to the exercise of discretion.

The Court said there was no additional external standard. The Plan language provided the administrator discretionary authority.

Booth Factor 8: The fiduciary’s motives and any conflict of interest it may have.

There may have been a structural conflict of interest, but the Court concluded “there is no evidence in the record that Aetna’s decision was influenced by the conflict.”

The Court concluded, “Plaintiff has failed to prove that Aetna’s decision was unreasonable under the Booth factors.”

This case was not handled by our firm, but we believe it can be instructive to those whose medical records currently may lack the support of their disability benefits claim. For questions about this case, or any question about your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

Leave a comment or ask us a question

FAQ

Do you help Aetna claimants nationwide?

We represent Aetna clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Aetna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Aetna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Aetna.

How do you help Aetna claimants?

Our lawyers help individuals that have either purchased a Aetna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Aetna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Dawn P.

I had to quit working after 8 years of dealing with chronic pain from 2 bulging and torn discs from an injury and failey back surgery. I was approved for Long term disability through my employer benefits, with Unum. They covered me with payments for one year, and suddenly sent a letter that their doctors disagreed with my surgeon and pain management doctors, and they felt I could go back to work full time. I hired a local attorney, trying to save some money, but I don’t think he had much experience dealing with big LTD companies such as Unum. He filed terrible appeals on my behalf with little to no effort on his part of building a good case for me. After a year of dealing with his condescending attitude and loosing my final appeal, I decided to call up Dell & Schaefer. I had contacted them a year prior when searching for an attorney. Cesar was willing to take my case and felt I had a good one. But I didn’t want to pay the percentage he was asking for if we won back then. The old saying, “you get what you pay for”, proved to be true in this case and I regretted not hiring him from the beginning!

Once I did hire him, and thank goodness he was still willing to take my case even though he was dealing with defending poor appeals by my previous lawyer, things got moving along for me. Because of his years of experience dealing with Unum, and his record of wins against them, within 6 months we had a settlement I could live with! The stress I suffered before Cesar and weight on my shoulders was gone! Cesar is a kind, caring, attorney who will fight for your rights! His assistant Michal always talked to me when I called in with questions or to check up on my case and never made me feel bad for calling. It was nothing like the previous relationship I had with my other attorney and his staff, who avoided me. Cesar explains the process well and keeps you updated on your options throughout the process. He was worth every penny!

I am grateful for their representation and would recommend anyone with an ERISA case to call him!

Read 432 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us