Aetna Removes 24 Month Limitation for Mental Health Conditions
For nearly six years, Attorney Stephen Jessup has been representing our client, a former chief in-house counsel in charge of compliance and regulations for a large corporation. When she first contacted our office and spoke with Attorney Jessup, Aetna had already been challenging her disability due in large part to what Attorney Jessup believed was on account of the large monthly disability benefit Aetna was paying her each month. Suffering from uncontrollable hypertension and secondary depression and anxiety, Aetna challenged her disability on grounds that her complaints were subjective in nature, and even though she had extremely high blood pressure she would not be prevented from performing her occupational duties.
Aetna’s early challenges to her claim culminated in a denial of benefits following “surveillance” conducted by Aetna that amounted to nothing more than observing her performing routine activities of daily living that in no way, shape or form were indicative of her ability to perform the extremely cognitively demanding duties of her former occupation. Attorney Jessup successfully appealed Aetna’s denial at that time and secured our clients monthly disability benefit based on her uncontrollable hypertension. However, over the next 5 years Aetna, and then Hartford after Hartford acquired Aetna, stopped at nothing to terminate our client’s claim.
Aetna determines our client is disabled from a mental health condition.
Like the overwhelming majority of employer provided ERISA group disability policies, our client’s policy contained a 24 month limitation for a disability caused by a Mental Health condition. Throughout the early history of our client’s claim Aetna had approved the claim based on her uncontrollable hypertension and at no point advised our client or Attorney Jessup that it had deemed her disabled due to a Mental Health condition or that Aetna was applying the 24 month limitation on account of same. Without question our client was suffering from depression and anxiety, but like many people on disability the depression and anxiety was not the cause of her disability- rather a byproduct of her physical medical conditions.
Approximately two years after Attorney Jessup initially successfully appealed the first denial of our client’s claim we received notice from Aetna that it intended to send our client to an Independent Medical Examination with a cardiologist to determine if our client’s hypertension was in fact disabling. Research into the IME doctor and conversations with our client’s treating physicians as to the IME doctor’s reputation in the medical community raised serious red flags as to the adequacy of the doctor and his ability to be truly independent and impartial. Attorney Jessup voiced his concerns to Aetna and requested that another doctor be selected. Aetna refused the request. Attorney Jessup’s concerns proved correct as the IME doctor found that our client would not be prevented from working on account of her hypertension. Upon receipt of the IME report Attorney Jessup coordinated with our client’s treating doctors and submitted three letters refuting the IME doctor’s findings and arguing that the IME doctor did not even have information regarding our client’s pre-disability occupation and as such his opinion had no proper context with which to determine if she could work.
Aetna decided to stand by the IME doctor’s opinion and in doing so indicated that our client’s claim was now only supported due to a mental health condition. Furthermore, Aetna advised Attorney Jessup that 24 months of benefits had already been paid under the mental health limitations- effectively ending our client’s claim. There was only one glaring problem- as mentioned above; at no point did Aetna previously approve benefits due to a mental health condition. Attorney Jessup argued this very important fact to Aetna and was able to get Aetna agree that our client would continue to receive 24 months of benefits under the mental health limitation.
Our client’s continued fight to prove disability due to a physical medical condition.
In asserting that our client was disabled due to a mental health condition Aetna did not issue a formal denial letter as to physical medical conditions, which meant Attorney Jessup would have the ability to argue our client’s right to continued benefits on account of her uncontrollable hypertension for the next 24 months while still preserving the ability to appeal once the 24 month mental health period came to an end.
By the end of the 24 month mental health period Hartford had already acquired Aetna and had taken over the handling of our client’s claim. Hartford’s evaluation as to our client’s disability mirrored that of Aetna’s and resulted in the denial of our client’s claim at the end of the 24 month mental health limitation period.
Again, Attorney Jessup prepared and submitted our client’s appeal challenging Hartford’s position that our client was not disabled on account of her uncontrollable hypertension. Understanding that Hartford did not want to pay our client’s large monthly disability benefit and the fact that Hartford would be afforded a great deal of deference under ERISA should our client’s claim be litigated, Attorney Jessup was meticulous in arguing the overwhelming medical evidence our client had to support her claim for disability while systematically attacking Aetna/Hartford’s logic and failings during the claim review process.
Benefits Approved.
After nearly two months had passed from the time Attorney Jessup submitted the appeal we were informed that Hartford was overturning the denial of our client’s benefit and was again deeming her disabled from performing the duties of her pre-disability occupation on account of her uncontrollable hypertension. Attorney Jessup and our client know that winning the appeal was only the next step in her claim’s history and that Hartford would not waste time in challenging her claim again. Attorney Jessup is now working to secure a lump sum settlement for our client so she can focus on her health rather than worrying about when Hartford would attempt to deny her claim again.
Is Aetna/Hartford ignoring your physical medical conditions?
It is very common for Aetna/Hartford to approve a claim for benefits based solely on a mental health condition in an attempt to limit financial liability to you. If you are experiencing this situation with Aetna/Hartford, or have concerns that your claim will be classified solely as a mental health claim please feel free to contact Attorney Jessup or one of our other disability insurance attorneys to discuss your situation in detail.
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