AETNA Life Insurance Company sued for failure to pay out disability benefits to ex senior nurse suffering from disabling mental conditions

On March 29th 2011, a lawsuit was filed against the AETNA Life Insurance Company (AETNA Life) at the District court for the Southern District of Florida. In the lawsuit, the plaintiff alleged that AETNA Life had refused to pay the disability benefits sought by the plaintiff under a group long term disability (LTD) benefits policy that was issued and administered by AETNA Life.

The Nature of the Complaint

The plaintiff was a Senior Emergency Room Registered Nurse employed by the University of Miami Hospital. As a result of his employment at the University of Miami Hospital, the plaintiff was a participant of a group insurance policy for LTD benefits that was issued and administered by AETNA Life. As a participant of the policy, the plaintiff was entitled to disability benefits in the event of him becoming disabled. Under the policy, “Disabled” was defined as:

From the day that you first become disabled and until Monthly Benefits are payable for 60 months, you will be deemed to be disabled on any day if:

  • You are not able to perform the material duties of your own occupation (full time or part time) solely because of disease or injury and
  • Your work earnings are 80% or less of your adjusted pre-disability earnings

After 60 months that any Monthly Benefits is payable during a period of disability, you will be deemed disabled on any day if you are not able to work at any reasonable occupation solely because of disease or injury.

The plaintiff as a result of suffering from several disabling conditions like obsessive compulsive disorder, bipolar disorder and psychotic hallucinations was prevented from performing the material duties as required under his occupation and any other reasonable occupation. Due to his inability to work, the plaintiff ceased working on November 24th 2008 and filed an AETNA disability claim.

As required under the policy, the plaintiff informed AETNA Life of his disabling conditions. Medical documentations relating to the plaintiff’s treatment was provided to AETNA Life to support the claim of being disabled. In addition, the plaintiff’s job description with the University of Miami Hospital was provided to AETNA Life. At the same time, the plaintiff’s attending physicians also consistently informed AETNA Life that the plaintiff is disabled as with the same conclusion drawn up by Social Security Administration. The Social Security Administration recognizing that the plaintiff was disabled, provided him with monthly Social Security Disability Income payments but made to a trusted individual due to the plaintiff’s mental health problems.

Despite the legitimacy of the plaintiff’s claim for disability benefits, AETNA Life on July 27th 2009 by way of correspondence denied the claim for disability benefits. According to AETNA Life, the “medical information received and reviewed failed to support functional impairments that would preclude [the plaintiff] from performing the essential job tasks of [his] occupation as a Senior Emergency Room Registered Nurse”.

Relief sought by the plaintiff under the lawsuit

Despite requesting a review of AETNA Life’s decision on January 25th 2010 and providing additional medical documentations from the plaintiff’s attending physicians and licensed therapists supporting the review, AETNA Life again denied the plaintiff’s claim for disability benefits on July 27th 2010. Exhausting all his administrative remedies with AETNA Life under the Employee Retirement Income Security Act (ERISA), the plaintiff has no recourse but to file a lawsuit against AETNA Life seeking:

  1. All the benefits that he is entitled to under the plan including of prejudgment interest retroactive to the day that the benefits were terminated;
  2. Reasonable attorney fees and costs as a result of pursuing this action against AETNA Life;
  3. Appropriate equitable relief which the court deem just and proper due to the act and omissions of AETNA Life.

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