Nevada disability lawyer and COX Enterprises Inc's customer service rep sue AETNA for denial of disability benefits
A former Customer Service Representative (CSR) for COX Enterprises Inc. (COX) recently filed a lawsuit through a Nevada disability attorney against the AETNA Life Insurance Company (AETNA Life) at the District Court for the District Court of Nevada. In Sandra Rada v Cox Enterprises Inc as Plan Administrator & AETNA Life Insurance Company as Claims Administrator, the plaintiff Sandra Rada alleged that AETNA Life had not provided the plaintiff with a full and fair review of her claim for long term disability (LTD) benefits and thus seek the Court to review Aetna Life’s decision under a de novo standard.
Aetna Disability Claim Denial History
The plaintiff, beginning January 1st 2005, was employed as a CSR with COX. Her duties as a CSR among other things included handling incoming customer calls; introducing and selling new or additional products or services; reviewing customer inquiries/problems and determining an appropriate solution or response; negotiating customer claims; initiating billing adjustments; arranging product substitution or returns; assessing customer needs; processing incoming orders; and providing clerical/administrative support to the customer service functions. As an employee of COX, the plaintiff participated in a Welfare Benefits Plan (which included a LTD flex plan) that was sponsored by COX. The Welfare Benefits plan also designated AETNA Life as the Claims Administrator.
On March 13th 2008, the plaintiff was involved in a motor vehicle accident. As a result of the accident, she sustained head trauma, scalp laceration which required 30 stitches, multiple contusions and injuries to the back and neck. Since the March 13th accident, the plaintiff alleged that she suffered from post-concussive syndrome which included anxiety, depression, headaches, memory loss, difficulty concentrating, word-finding problems, sleep disturbance, confusion and fatigue. Prior to the March 13th accident, the plaintiff also had a history of chronic back and neck pain due to two previous motor vehicle accidents. She was already having medical treatment for these past injuries when the March 13th accident aggravated her condition.
Definition of ‘Total Disability’ under the Aetna Disability Plan
Under the Welfare Benefits plan that the plaintiff participated in, the plan defined total disability as:
In the first 24 months of a period of total disability: You are not able, solely because of injury or disease, to work at your own occupation.
After the first 24 months of a period of total disability: You are not able, solely because of injury or disease, to work at any reasonable occupation. (This is any gainful activity for which you are, or may reasonably become, fitted by education, training or experience. It does not include work under an approved rehabilitation program.)
Due to her medical conditions, the plaintiff applied for long term disability benefits under the above mentioned plan in August 2008. The claim was approved and AETNA Life paid LTD benefits to the plaintiff from September 14th 2008 through April 9th 2010. Concurrently, the plaintiff also applied for social security disability benefits which was approved and awarded to the plaintiff on January 22nd 2010 by the Social Security Administration (SSA). In its determination, the SSA deemed the plaintiff as being disabled from December 6th 2009. Aetna gladly deducted the amount of the social security disability award from the plaintiff’s check each month. Despite the findings of SSA, Aetna later disagreed with the SSA findings of total disability.
Conversion of Disability Definition from ‘Own Occupation’ to ‘Any Reasonable Occupation’
On February 25th 2010, the plaintiff’s case was referred by AETNA Life for a peer review by an occupational medicine specialist. The specialist hired by Aetna opined that the medical documentations provided by the plaintiff did not support a functional disability from any occupation. The review was forward to the plaintiff’s attending physician by AETNA Life for comment and requested an explanation or documentation if the attending physician did not agree with the opinion of the occupational medicine specialist. ATENA life also requested that the attending physician responded within 15 days which unfortunately the attending physician did not do so until April 22nd 2010.
An Occupational Analysis prepared by AETNA Life on April 8, 2010 concluded that the plaintiff would be able to engage in several different occupations based on her training and education and on the findings of its peer reviewer that she could work a sedentary job. Thus, AETNA informed the plaintiff on April 14th 2010 that it was terminating the plaintiff’s LTD benefits effectively from April 9th 2010. The ground for the termination of the plaintiff’s LTD benefits was that she was not disabled from any reasonable occupation due to the lack of response from her attending physician to the peer review and an absence of “objective medical evidence of restrictions precluding her from working a full-time sedentary job.”
The Appeal of AETNA Disability Claim Denial
The plaintiff in view of AETNA Life’s decision to terminate her LTD benefits submitted an appeal to the decision on January 10th 2011. Further medical documentations and clarifications were provided by the plaintiff to AETNA Life to support her appeal. In February 21st 2011, AETNA Life “partially overturned” its April 14th 2010 decision. It extended benefits to the plaintiff from April 9th 2010 to November 30th 2010. It refused to pay LTD benefits beyond November 30th 2010 because
the records presented for review do not provide any abnormal examination findings, imaging studies, or behavioral observations, dated after 11/30/10, to document any specific impairment that would prevent [her] from performing the work of any occupation.
According to AETNA Life, this decision was based on three physician reviews and peer-to-peer conversations conducted.
The Claim For Relief
As a result of ATENA Life refusal to consider its denial of LTD benefits to the plaintiff beyond November 30th 2010, the plaintiff was forced to file a lawsuit against AETNA Life for the wrongful denial of benefits under ERISA. In the lawsuit, the plaintiff alleged that AETNA Life failed to consider the medical opinion of her attending physicians and the determination of her disability status by the SSA and arbitrarily terminated her LTD benefits. As such, the plaintiff is seeking the following relief from the court:
- Review the termination of benefits under a de novo standard of review
- Declare that she is entitled to past LTD benefits from December 1, 2010 through the present
- Reinstatement of her LTD benefits
- An award of pre-judgment interest through the date of payment
- Payment of attorney’s fees and costs associated with attempting to secure the benefits owed to her
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
