In July 2016, Kimberly Garner, suffering from urinary incontinence, left her job with Amazon, and filed a claim for long-term disability benefits with Amazon’s long-term disability insurer, Aetna Life Insurance Company.
The Amazon Long-term Disability Plan required that in order to receive monthly benefits, the employee insured must be unable to “perform the material duties of [their] own occupation solely because of an illness, injury or disabling pregnancy-related condition; and [their] work earnings are 80% or less of [their] adjusted pre-disability earnings.”
Ms. Garner had suffered with the complications of her condition since at least 2009. She had seen a urogynecologist, undergone several surgeries, and even undergone botox treatment – usually reserved for women for whom other treatments had failed. Her treating physician noted that testing showed a “diminished bladder capacity” and that she continued to experience urge incontinence and stress incontinence. Despite the overwhelming evidence in support of her disability claim, Aetna denied her disability claim, as well as her subsequent appeals.
As for its basis for denying Ms. Garner’s disability claim, Aetna justified its decision based on the reviews and opinions of a physician and nurse consultant it had engaged to perform a medical review of Ms. Garner’s claim.
After having exhausted her administrative appeals with Aetna, Ms. Garner filed suit in Federal Court alleging that Aetna had violated ERISA when it had denied her disability claim. Ms. Garner sought recovery of the disability benefits that Aetna had failed to pay and reinstatement of her claim. Ms. Garner argued and the Court found that Aetna had not considered all of the medical evidence and that the opinions of Ms. Garner certifying doctor were disregarded and rejected in favor of the opinions of the physician and nurse Aetna had consulted. The evidence showed that Ms. Garner’s condition had not improved and that her symptoms had been reported by her treating physicians as being severe and persistent.
However, despite finding that Aetna’s decision was unreasonable “based on primarily insufficient reasoning”, and concluding that Aetna’s denial of benefits was indeed arbitrary and capricious, the Court, instead of awarding Ms. Garner the benefits she was rightly owed and deserved, remanded the case to Aetna for further review. The Court did however leave the door open for Ms. Garner to file a petition for attorney fees based on the her success on the merits of her disability claim. It is within the Court’s discretion in ERISA disability cases to award or deny attorney fees to a prevailing party.
Although this case was not handled by our firm, it is an important Court decision for any claimant needing assistance with a disability insurance denial. If you have been denied disability benefits by Aetna or any other disability insurance company, please do not hesitate to contact Dell & Schafer for a free consultation.