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Question

Why has Aetna denied my LTD claim I am objectively disabled?

Asked on January 28th 2016 by John
Dear Sir’s, I had Aetna short term disability and it continued to it’s entirety, 26 weeks. When it was time to continue or switch over to long term disability, I was denied. I have appealed the denial and I am currently waiting to hear from an Aetna rep. It was difficult with the short term disability because Aetna requested paperwork almost every 2 weeks from my doctors. It started in the spring of 2015, I went to my primary doctor as I was having costant dizziness and near fainting episodes. I was taken out of work and was subjected to so many test’s to figure out what was going on. They thought it was my heart, my blood pressure, brain tumors, vasal vagal problems and so on. There were so many test’s that did not show anything wrong until I went to a balance and dizziness center for VNG testing, caloric testing. The test results showed that I have a vestibular labyrinthine loss on my left side only (unilateral). Up to this point, Aetna said that all of my symptoms were suggestive and there was no evidence of anything wrong with me. Since having this VNG/caloric test it has been proven that I have this problem. This is now objective/positive proven results that This vestibular loss/disfunction exist’s. My question is why has Aetna denied my LTD since the facts are irrefutable? This is why I appealed the denial and I am hoping that my LTD will be approved. Any thoughts on this? What should I do if I am denied again? I cannot work or function at home because of this vestibular loss. It is really bad and most people don’t understand what it is like to be constantly dizzy and feeling like I am going to fall down, holding onto the walls to manuever in my house and need the use of a cane when there are no walls. I have so many other problems from this that I don’t want to write all now, but I wanted to reach out to You for some insight. Not sure where to turn because the bills are piling up and I have no money coming in. Please help me with some information. Thank You, John from New York.

Answer

Answered on January 28th 2016 by Attorney Stephen Jessup

John, the denial is likely due to the concept that “Diagnosis does not equal disability.” Meaning, having the diagnosis alone does not mean you are unable to perform the duties of your occupation. To prove disability you have to establish how the diagnosis is resulting in restrictions and limitations as they would relate to work. As your appeal has been submitted, and Aetna could realistically render a denial at any time, it would be best to act quickly to provide any documentation from your doctors to address that point. Aetna typically only allows one level of appeal, so if your claim is denied your only option would be to bring a lawsuit. If your claim is governed by ERISA only the information in the claim file at the time of the final denial can be considered by a Judge, as such it is crucial to have all medical evidence of your restrictions and limitations to them before that potentially happens. In the event your claim is denied on appeal please feel free to contact our office to discuss how we may be able to assist you in litigating the matter. I hope this shed a little additional light on your situation.

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