Aetna Disability Denial Upheld - Dell Disability Lawyers
In Jordan Harper v. Aetna Life Insurance Company, (Aetna), Plaintiff’s husband, Douglas Harper, died on December 31, 2017, in a single car accident to which there were no witnesses. The accident report noted there were no skid marks or any indication the driver of the car took any evasive action.
The death certificate showed the cause of death as “multiple blunt force injuries.” The autopsy report and the toxicology report showed that Mr. Harper was under the influence of both amphetamine and methamphetamine at the time of his death. Although he had a prescription for the medication, Adderall, which is an amphetamine, methamphetamine is an illegal Schedule II controlled substance. The toxicology report also indicated that the decedent had more amphetamine in his system that he would if he had only taken the Adderall according to the prescribed dose.
At the time of decedent’s fatal accident, he was employed by Integrated Services Company (Inserv) which, as part of its employee benefit plan (Plan), provided its employees with an accidental death and personal loss (ADPL) insurance policy. The policy was issued by Aetna which acted as both the administrator and payer of the claims.
One clause of the policy specifically stated that:
“No benefits are payable for a loss caused or contributed to by: Use of alcohol or intoxicants or drugs, while operating any form of a motor vehicle whether or not registered for land, air or water use. A motor vehicle accident will be deemed caused by the use of alcohol, intoxicants or drugs if it is determined that at the time of the accident you or your covered dependent were: Operating the motor vehicle while under the influence of an intoxicant or illegal drug; or Operating the motor vehicle while under the influence of a prescription drug in excess of the amount prescribed by the physician…”
Plaintiff, the wife of the decedent and also an Inserv employee, was the beneficiary of her husband’s ADPL policy. When she filled a claim for the death benefits, Aetna denied her claim on the grounds that the intoxication exclusion applied. Her administrative appeal was denied so she filed this ERISA lawsuit in the U.S. District Court for the Northern District of Oklahoma. She raised several issues, primarily that Aetna abused its discretion in denying her claim for death benefits.
The Court disagreed with Plaintiff and found it reasonable for Aetna to deny death benefits to her. The Court held that the plain language of the policy made it clear that since the toxicology report made it clear that her husband had amphetamine and methamphetamine in his blood stream at the time of the accident, the intoxication exclusion applied and Aetna did not abuse its discretion, and its decision to deny her death benefits was not arbitrary and capricious.
Application of the Intoxication Exclusion
The Court noted that “In determining whether Aetna abused its discretion in denying plaintiff’s claim, the Court must consider whether it was reasonable for Aetna to find that decedent was under the influence of intoxicating drugs at the time of his death.” In making its decision the Court reviewed the same items Aetna reviewed in determining the intoxication exclusion applied and Plaintiff was therefore not entitled to death benefits. The documents included, among others:
- The death certificate. Cause of death was listed as due to “multiple blunt force injuries.”
- The Official Oklahoma Traffic Collision Report. There were “no skid marks or yaw marks on the road to indicate evasive movement from [the] vehicle.”
- The toxicology report. This showed the decedent’s toxicology was positive for methamphetamine and amphetamine.
- The autopsy report. This included information that in the car at the time of the crash, there was “a pipe containing a green leafy substance.”
- The lab analysis. Decedent’s toxicology report was positive for 0.35 mcg/ml of amphetamine and 2.2 mcg/ml for methamphetamine.
- Decedent’s prescriptions history. Decedent was taking the prescription drug, Adderall, which is an amphetamine.
Plaintiff argued that relying on the toxicology report alone was an abuse of discretion and that it should have hired an expert to analyze the report. She also argued that Aetna should not have relied on the claims analysis and registered nurse who reviewed the toxicology report and used a wrong chart in determining the blood levels of the decedent.
The Court found that it didn’t matter what chart was used, the toxicology report showed that “decedent tested positive for methamphetamine” which is a Schedule II illegal drug.
The Court held “not only did Aetna act reasonably in its decision to deny life insurance and basic and dependent ADPL benefits, but also its decision is supported by substantial evidence based on the intoxicant and illegal drugs exclusion.”
This case was not handled by our firm, but we believe it can be instructive for those who are wrestling with their insurance company over a claim for death benefits and the company is claiming it has no obligation to pay benefits under an intoxication exclusion. If you have questions about this case, a question about collection of accidental death benefits, or a question about a claim for short-term or long-term disability (LTD) benefits, contact one of our attorneys at Dell & Schaefer for a free consultation.
You can read about Aetna disability claims on this page.
Resources to Help You Win Disability Benefits
Disability Benefit Denial Options
Submit a Strong Appeal Package
We work with you, your doctors, and other experts to submit a very strong appeal.
Sue Your Disability Insurance Company
We have filed thousands of disability denial lawsuits in federal Courts nationwide.
Protect Your Benefits
Get Your Disability Application Approved
We help claimants throughout the entire application process.
Prevent a Disability Benefit Denial
We manage every aspect of your disability claim following claim approval.
Negotiate a Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Aetna Reviews
(656)
Policy Holder Rating
5
0%
4
0%
3
0%
2
62%
1
37%
Timely Payments
1.9out of 5
Handling Claim
1.9out of 5
Customer Service
2.0out of 5
Dependable
2.1out of 5
Value
2.1out of 5
Showing 8 of 656 Reviews
Aetna
Aetna STD has been a nightmare since the beginning
I had surgery on 2/27/2020. Aetna STD has been a nightmare since the beginning. Total mismanagement of everything. I have never been paid consistently & have had to manage... read more >
Reply
Aetna
Aetna leaves me at risk of losing my job and without compension
I applied for STD 2/24/2020 for eye surgery. Documents were submitted. Aetna noted they contacted the doctor and needed the APS form; already was submitted. So, the dr sub... read more >
Aetna
Aetna puts their clients through hell with their games
I have been on Aetna disability for a couple of years now and have surround sound to be extremely cunning and ruthless. They put put claimants through hell for the first 6... read more >
Reply
Aetna
It's been over 3 months, and I've only received one payment from Aetna
I have been struggling with Aetna to get my short term disability, its been since 10/16/2017 and I have only received one payment since. My doctors send in my forms and th... read more >
Reply
Aetna
Aetna people are thieves, crooks and liars.
It is my opinion that Aetna people are thieves, crooks and liars. I purchased a disability policy from my employer with Aetna. I became disabled because of a heart conditi... read more >
Aetna
Aetna is definitely committing a crime and they need to be stopped.
Aetna denied my claim after providing all my doctor notes 5 times, all my ER records. stating that i did not see my doctor until 3/3/17 but my out of work date was 2/16/17... read more >
Reply
Aetna
I hate Aetna
My story is the same as most here. I suffer from several afflictions. T1 diabetic for 42 years, stage 3 kidney disease, neuropathy pain in feet legs and hands, carpal tunn... read more >
Reply
Aetna
Aetna denied me and then I got fired from my job
I got denied and got fired right after my Dr submitted my paperwork for leave, due to being in the hospital. They fired me for being in the hospital. and now paying unempl... read more >
Reply
Answered Questions by Our Lawyers
(30)
Showing 8 of 30 Answered Questions
Q: Can Aetna deny my application on the basis of pre-exisiting condition? Do they discriminate against the mentally ill?
A: Molly, unlike health insurance plans, a disability insurance carrier can deny application for coverage based o... Read More >
Q: Are there any circumstances in which I can appeal LTD after the number of days Aetna gives you to appeal?
A: Sharon, usually the insurance carriers are pretty strict and adhere to the appeal deadline which is set out in... Read More >
Q: Can Aetna deny my claim due to a "war exclusion" on my policy?
A: Phil, I am sorry to hear about your difficulties. Have you filed an appeal of the denial? All disability insur... Read More >
Q: What do I do if Aetna claims they haven't received my medical info?
A: Roberta, you should contact Aetna to verify that they actually received the information and find out if they a... Read More >
Q: How can Aetna say I am not disabled when clearly I am?
A: Laurie, unfortunately Aetna can hire their own doctors to disagree with yours and claim you can work even if y... Read More >
Q: Is the 2nd appeal process worth it or a waste of my time?
A: Rebecca, I would certainly say it is worth it. If he filed for disability in September 2016 and the change in ... Read More >
Q: What can I do to stop Aetna from harassing me and realize that not all disabilities are the same?
A: SO, it certainly sounds the Aetna is setting your claim up for a denial. Please feel free to contact your offi... Read More >
Q: Can Aetna deny my claim for STD due to pregnancy because it was preexisting?
A: Slavka, unfortunately, disability insurance policies come with pre-existing condition provisions that are enfo... Read More >
Helpful Videos
(908)
Showing 12 of 908 Videos
Disability Benefit Tips
(331)
Showing 8 of 331 Benefit Tips
Does Social Security Approval Mean Disability Insurance Benefits Will Be Paid?
The answer to this question is NO and a recent case brought by a FEDEX employee against Aetna insurance company is an example of an SSDI approval and a long term disability denial. In a recent case, a Fed-Ex employee filed a lawsuit against AETNA following the denial of long term disability benefits. Aetna paid long-term disability benefits for 24 months and then denied benefits when his definition of disabili... Read More >
Does a disability insurance company need to consider the side effects of my medications?
Disability insurance companies are notorious for ignoring the cognitive side effects that most disability claimants experience from their medications. Disability companies are aware of the side effects of narcotics; yet they often fail to consider how working under the influence of these prescribed drugs limits a person's ability to work. Disability benefit comp... Read More >
Does the Mental Nervous Disorder Limitation in an ERISA Long Term Disability Plan Violate ADA Laws?
According to several Federal district courts throughout the country the answer to this question has historically been that the American with Disability Act (ADA) laws does not apply to an ERISA long term disability policy provided by an Employer. The reason the ADA has been found not to apply is because of a concept called ERISA Preemption. ERISA Preemption means that since ERISA is a Federal law it overrules ... Read More >
Is it legal to limit disability insurance benefits to 24 months for mental nervous claims?
The question listed below was recently posted on our disability blog, but since it is a question that we receive on a weekly basis, we decided to make it a frequently asked question.Thank you so much for this blog and your site. It is truly a resource for anyone with an ERISA claim.From the start things are skewed when you have a "mental health" diagnosis. The inequities the mental health community has had... Read More >
Why Must Your Disability Insurance Lawyer Understand Your Disabling Condition?
When it comes to securing your disability insurance benefits, it's vitally important that your disability insurance lawyer thoroughly understands the symptoms and impact of your disabling condition. Doctors can help you create strong medical records, but they're not accustomed to dealing with the rigorous documentation disability insurance companies require. Lea... Read More >
Disability Benefit Denial Reason #5 – Your Medical Evidence is Weak
If you're seeking long term disability benefits from an insurance company, you may be concerned that you're facing an uphill battle. Fortunately, the stronger your medical evidence, the greater the odds that your claim will be approved. On the other side of the coin, one of the most common reasons for denial of long term disability benefits involves too-weak med... Read More >
Disability Benefit Denial Reason #4 - Your Doctor Is Misled By the Disability Company
When you're seeking disability insurance benefits, your medical records and treating physician's statement are two of the most important components of your claim. But because the insurance company has a vested interest in denying your disability insurance claim, it often will rely on tactics like ambushing your doctor with a phone call in an attempt to get them ... Read More >
Disability Benefit Denial Reason #3 - Video & Social Media Surveillance
One thing many disability insurance claimants don't know about (or expect) from the claims review process involves video and social media surveillance. Disability insurance carriers often hire people to follow claimants around with a telephoto lens - or even send social media friend requests from fake accounts - to glean whatever information they can about the c... Read More >
Dell Disability Cases
(375)
Showing 8 of 375 Dell Disability Cases
Aetna Overturns Denial of Long Term Disability Benefits for Quality Control Manager
Our client, Mr. J, formerly worked as a Quality Control Manager for a large home furnishings store. For many years Mr. J suffered from the debilitating effects of his chronic, organic medical conditions and associated cognitive deficits, including transient cerebral ischemia and chronic migraines, which left him with significant physical and cognitive impairments. As a result of his serious medical conditions ... Read More >
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 pa... Read More >
Aetna Overturns Denial of LTD for Former Employee of The Home Depot
Prior to enlisting our services to challenge a denial, our client had received benefits from Aetna due to his disabling conditions for 18 months. Unfortunately for our client, Aetna decided to deny benefits due to the “change in definition of disability.”Common in most group disability insurance policies, the change in definition typically happens after benefits have been paid for 18 or 24 months. For ... Read More >
Aetna Reinstates Benefits for Former SAP America Employee Suffering the Effects of a Head Injury
My now client worked for SAP America, Inc. as a Senior Solutions Sales Executive for nearly seven years. She made a great salary working at a job and employer she loved. Her work required superior cognitive and analytical skills and was both challenging and rewarding. Unfortunately for her, in December of 2016, she suffered a serious head injury. While she attempted to remain working, as of January 2017 her sy... Read More >
Aetna overturned previous denial of long term disability benefits for Georgia Assistant
Our client, Ms. A, formerly worked as an executive assistant for a town administrator. In April 2014 a number of co-morbid physical conditions and ailments forced Ms. A to stop working and submit her claim for disability benefits under her employer’s Long-Term Disability (“LTD”) Policy which was administered and funded by Aetna. Under the employer’s disability policy Ms. A would be considered totally d... Read More >
Dell Disability Lawyers file Lawsuit in Federal Court against Aetna after it denied long-term disability benefits to former software Developer
In 2011, while working as a software developer for a different company, Charles suffered a cerebral vascular attack (CVA). Despite suffering a stroke, after a period of recovery, Charles returned to work, but for a different employer. In 2014 Charles migraines increased and he began having significant problems with his short-term and long-term memory. He also found that he was having significant difficulty per... Read More >
After Aetna denied Ms. Garner's long-term disability claim, Ms. Garner filed suit against Aetna, and the Court overturned Aetna's decision and ordered it to pay Ms. Garner's disability benefits
In 2004, Sally took a leave of absence from her job as an import supervisor for a global shipping company to undergo surgery for an internal left knee derangement. During that time she had also been suffering from severe symptoms of depression following her son’s departure to college and the at-home environment changing. Her doctors diagnosed her with bipolar disorder II and placed her on depression and anxi... Read More >
Aetna Reinstates Disability Insurance Benefits to Home Depot Manager
Prior to disability our client worked as a Warehouse Distribution Operations Manager for Home Depot, a job that not only required supervision of employees, but a significant amount of physical ability. However, a long fight with uncontrolled diabetes and severe diabetic neuropathy reached a point where he was no longer able to meet the physical demands of his occupation leaving him with little choice but to fi... Read More >
Disability Lawsuit Stories
(765)
Reviews from Our Clients
