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Aetna denial of long-term disability benefits for chronic fatigue syndrome upheld by Court

Physician’s Failure to Fill Out Functional Limitations Paperwork Costs Man Rightful Benefits

A supporting physician is essential for any claimant to receive long-term disability benefits. However, a treating physician must do far more than just diagnosis a disabling medical condition. The decision rendered by the U.S. Court of Appeals, Seventh Circuit in Williams v. Aetna Life Insurance Company continues to have an impact on long-term disability decisions in U.S. Courts even though it has been over two years since Lee K. Williams lost his appeal against Aetna Life Insurance Company (Aetna) and The Sysco Corporation Group Benefit Plan (Plan). Williams’ unsuccessful attempt to secure a Court reversal of his long-term disability denial for chronic fatigue syndrome (CFS) continues to shape the strategies of disability attorneys as they help their clients perfect their claims for this non-objective ailment.

Williams, who was 48 at the time of the court decision, had been a truck driver for Sysco since November 1994 until his CFS made it too exhausting to continue working on July 26, 2002. His job wasn’t completely sedentary. Despite the fact that he spent many hours on the road, he helped unload the deliveries. This meant he might have to lift 100 lbs., climb ladders, kneel, twist and stoop for up to two hours of his day. Aetna considered these occasional work responsibilities. He spent up to another four hours of the day lifting up to 50 lbs., climbing stairs, pushing, pulling, reaching, grasping, sitting, standing, walking, and using his fine and gross manipulations skills. Aetna considered these frequent job required tasks. Finally, the continuous job requirements, which could occur throughout his eight-hour day, included lifting up to 20 lbs., carrying up to this amount of weight and bending.

As a participant in the Sysco Corporation Group Benefit Plan, Williams expected to be able to collect benefits after he became ill on July 26, 2002 and had to be admitted to the hospital for his symptoms – fatigue, shortness of breath, dizziness and cough. Even after his release, his symptoms continued, so he underwent a series of tests to determine the cause of his symptoms. Dr. John Sorin, an immunology and CFS specialist at Northwestern Hospital, ruled out other conditions before he reached the conclusion that Williams had CFS.

In February 2003, Williams applied for long-term disability benefits under the Aetna Disability Plan. Dr. Sorin submitted an Attending Physician Statement informing Aetna that Williams had been diagnosed with CFS. Dr. Sorin expressed his opinion that Williams had a Class 5 impairment – unable to perform even minimal sedentary activities.

Aetna asked Sysco, in March 2003, to provide a physical demands analysis for Williams’ truck driving position. Armed with this information, Aetna sent Williams’ application to Dr. Brent Burton for review. Dr. Burton’s evaluation stated that the medical data in the file failed to provide documentation that Williams had a diagnosable medical condition that accounted for his subjective symptoms of fatigue. The data from physical examinations showed no evidence that Williams had lost his range of motion, strength, coordination or ability to feel. Dr. Burton also found that none of the information in the file indicated that Williams’ impairment was significant enough to prevent him for working as a truck driver.

On May 12, 2003, Aetna notified Williams that the disability insurance plan was denying his claim because to quote Dr. Burton “[T]he medical data in this case do not provide any documentation that Mr. Williams has a diagnosable medical condition that explains his subjective symptom of fatigue. The physical examination data do not reveal evidence of significant loss of range of motion, strength, sensation, coordination, etc., to justify discontinuation of workplace activities. There is no data to indicate that Mr. Williams has sufficient impairment to render him unable to work in his usual occupation as a truck driver.”

Physician fails to complete residual functional capacity questionnaire completely.

Williams appealed Aetna’s decision. Dr. Sorin sent the long-term disability Plan administrator a note on May 19, 2003 stating that he was treating Williams for CFS. In his opinion, even though Williams was showing signs of improvement, the truck driver was still unable to resume work. Aetna asked the doctor to fill out a CFS residual functional capacity questionnaire. Dr. Sorin returned the questionnaire on August 11, 2003, but it was not filled out completely.

While Dr. Sorin did fill out the section dealing with how Williams’ fatigue constantly interfered with his ability to concentrate and focus, he failed to provide explanations to support some of the other conclusions he had drawn. When asked to provide his estimate for how long Williams could perform certain activities, he provided partial answers. For example, when asked how many hours Williams could sit or stand at one time, the doctor wrote “unknown” in the margin. He stated that Williams could lift 10 lbs. occasionally, but failed to indicate if he could lift any higher weights. He stated that Williams had significant limitations when repetitive reaching, handling and fingering were involved, then later stated that he had not tested Williams to evaluate how long Williams would be able to perform these activities each day.

Disability attorney files ERISA appeal of Aetna disability denial decision.

Williams’ disability attorney wrote a formal appeal letter to the disability insurance company on September 10, 2003. Aetna upheld its denial of disability benefits on January 9, 2004, after considering the additional information supplied by Dr. Sorin. The denial pointed specifically to the Dr. Sorin’s report that had stated several times that Williams had not been tested for functional limitations for the very activities he was claiming he could no longer perform. The disability insurance Plan stated clearly that without this evidence, Aetna could not reverse its decision. His file was closed. Williams’ attorney should have considered having his client undergo a functional capacity evaluation.

Disability attorney advises Aetna that his client was approved for SSDI and files ERISA lawsuit

On July 28, 2004, the disability attorney requested a copy of Williams’ claim file. He also notified Aetna that the Social Security Administration had deemed Williams disabled. When this information failed to prompt Aetna to reverse its denial of benefits, Williams filed suit against Aetna and the Plan under the Employee Retirement Income Security Act (ERISA) section § 1132(a)(1)(8). The District Court ruled in favor of Aetna and the Plan on September 28, 2004.

Disability attorney files appeal of District Court decision.

Williams’ disability attorney filed an appeal with the U.S. Court of Appeals, Seventh Circuit. In evaluating the correctness of the District Court’s decision, the judges hearing arguments had to follow carefully the guidelines established by ERISA. Because the long-term disability Plan gave Aetna discretion to determine whether Williams was eligible for benefits and to interpret the terms of the Plan, the Court of Appeals had to consider Aetna’s decision under the arbitrary and capricious standard, just as the District Court had. The judges also could only listen to arguments that had been presented before the District Court.

Because Aetna’s decision fell under the arbitrary and capricious yardstick, the Court only had to determine whether Aetna’s decision was reasonable in light of the evidence in the records kept of Williams’ claim. His disability attorney argued that Aetna’s decision was not supported by the record.

In conclusion, the Court found that Williams’ disability attorney had failed to present any arguments that proved Aetna had made an arbitrary and capricious disability benefits denial. The Court of Appeals affirmed the decision of the District Court and granted summary judgment in favor of the Sysco Corp. Group Benefit Plan.

The primary lesson to be learned from this case is the value of medical information that clearly supports a disability attorney’s client’s disability claim. Treating physicians are not trained to answer insurance company medical questionnaires. A treating physician’s failure to document restrictions and limitations will always jeopardize a claimant’s disability claim. The insurance company are trained that diagnosis does not mean disability. As result, a claimant’s medical records must clearly document restrictions and limitations. If an experienced disability attorney becomes involved in a claim he/she should be able to identify this type of issue, and possibly save his/her client from a long, yet unsuccessful legal process.

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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.

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Leza A.

Desperarate & feeling like I was on a raft floating farther… out to sea. By the time I was diagnosed (it was close to a year) with fibromyalgia. I was in so much pain “ALL” over my body, feeling desperate for relief of my pain and the feeling of foggy headed (foggy headed is one of the conditions of Fibro). I wasn’t getting better instead my pain was getting worse. I was thinking about my career that I worked so hard to get where I was. I more than missed and loved my career.

My husband used to say that I loved my career more than him (so wasn’t true) but, I would do things like cancel a trip (40th birthday trip) in order to get the job done at work/make it happen (New Home R/E Sales). My career was a “very” physical and also required to be mentally sharp at all times.

What I thought at the beginning of feeling ill was going to be out from work for maybe a few days to a week, didn’t happen. Then I got to the point of being out from work for a year and realizing this was going to be a challenging and long road. In dealing with the short/long term disability company was getting to the point I couldn’t handle it. So… I got on the computer when I had short breaks from being foggy minded (took weeks of searching). So the search for someone/company who could take the challenge to keep up with the demands of paper work from the disability company with my short/long term disability company and who was successful at fighting this kind of case and with my medical diagnoses of fibromyalgia (I had been denied after the first few months of short term disability). I found Dell & Schaefer Law Firm who had a successful out come with not only the disability company that I had but, also against working with a fibromyalgia case.

I am blessed to have come across Dell & Schaefer and then I was blessed to have/be working with Rachel Alters! I found it was/hasn’t been easy in any way to deal with a case of fibromyalgia but, I am so more than happy I have/am working with Dell & Schaefer “Rachel Alter”. If I was up to it (not with fibro) I would be dancing all night long celebrating (I loved to dance all the time before fibro)! The many… appeals, time and all the hard work it took, my/our case has been over turned! I was caught off guard when I received the call from Rachel Alter! When I answered it I was thinking we were needing more documentation or another specialists to state where I am with my illness but, I got the best news in years and I just started crying out of control with tears of happiness! Tears of happiness have not been a part of my life in many years. Yea!!!!!! FYI… This was a challenge for me to write due to not being able to sit or type due to my pain of fibromyalgia but, so worth sharing my experience with choosing Dell & Schaefer “Rachel Alter & Team” ! Again… I am so blessed to have contacted Dell & Schaefer!!! Thank You Dell & Schaefer “Rachel Alter & Team”… :-)

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