Aetna Life Insurance Company denies disability benefits and claims physical therapist with back disorder can perform “reasonable occupation”

Sandy Brooks Scott filed a lawsuit against Aetna Life Insurance Company in the Circuit Court of the City of St. Louis, Missouri requesting that she be awarded long term disability benefits as well as attorneys’ fees and court costs.

According to Scott’s ERISA-covered group insurance policy her plan is “a Monthly Benefit for a period of disability caused by a disease or injury.” Her plan describes a person as being disabled if that person is unable to perform the “material duties” of their occupation and their wages are “80% or less of pre-disability earnings.” And any day that that person is unable to work at a “reasonable occupation” due to their disability or injury after the first 24 months, they are eligible for disability benefits.

Scott’s Disability Insurance Claim Against Aetna Life Insurance

In Scott’s case, she stopped working because of severe spondylosis on May 21, 2007, and applied for long-term disability benefits after the 90-day waiting period as prescribed by her Aetna Life Insurance Policy. Consequently, Scott received her disability benefits for the first 24 months under the “own occupation” stipulations of her policy.

As a physical therapist, Scott earned $24.75 per hour; and her initial disability benefits were calculated according to this rate of pay. She received $3,438.73 per month for the initial 24 months after she qualified for disability benefits and was unemployed during that time. Once the initial 24 months were complete, Aetna stopped paying Scott’s disability benefits from November 21, 2009 until May 2010, allegedly short-changing Scott by $17,193.65 in unpaid disability benefits.

In May 2010, Scott found relief when her Social Security Administration disability payments began, resulting in an offset of the Aetna benefits. However, Aetna still owed Scott $1,315.73 per month according to the terms of her plan. And, since Scott has remained disabled and unable to work, Aetna continues to accumulate unpaid benefits in the amount of $1,314.73 per month. It is extremely unfair that Aetna will accept the social security disability offset funds, yet refuses to agree with the social security finding of total disability.

Having met all of the ERISA administrative deadlines and performed all obligations as specified under the Aetna plan, Scott was reported to be disabled under three vocational reports for her own occupation. On June 6, 2010 Coventry Health Care conducted a survey to determine if “a reasonable job” was available for Scott at her previous pay of $24.75 per hour. While their report did not make a determination of employment, it did report that more research should be conducted; and on February 2, 2011 a labor Market Survey was conducted in Scott’s case. Previously, on July 16, 2009, a rehabilitation specialist had said that Scott was employable. However, at that time, Scott could not find any employment for which she qualified that she could perform under her previous pay rate.

After researching possible employment options, Scott appealed her claim, saying, “she did not have a PHD” because she did not finish her dissertation and did not qualify as a teacher or professor as an Aetna rehabilitation specialist had suggested. Unable to perform as a physical therapist and unqualified to teach or find employment at her “own occupation,” Scott qualifies for disability benefits under her Aetna policy.

In her complaint, Scott’s St. Louis disability lawyers argue that since Scott cannot find a sedentary job that meets her pay criteria, she is entitled to her long term disability benefits. Consequently, they allege that Aetna abused its discretion in denying Scott her long-term disability benefits and have turned the situation over to the Court to decide.

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