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Aetna Life Insurance Company overturned previous denial of long term disability benefits for Georgia Assistant

Attorney Jay SymondsAuthor: Attorney Jay Symonds

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 disabled after the first 24 months of her disability if she was unable to work at any reasonable occupation solely because of an illness or injury. A “reasonable occupation” was considered any gainful activity for which she was, or may reasonably become, fitted by education, training, or experience, and which results in, or can be expected to result in, an income of more than 60% of her adjusted pre-disability earnings.

After paying Ms. A for 24 months under the LTD Policy, Aetna denied her further LTD benefits on the basis that she allegedly did not meet the policy definition of disability. Specifically, Aetna determined that she was “not totally disabled from performing any reasonable occupation for which you are qualified for by education, training or experience” and identified several occupations she allegedly could perform. After receiving the denial, Ms. A contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Aetna’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. A’s ERISA appeal with the assistance of his appeal team.

The LTD appeal addressed all of Aetna’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Aetna’s denial. The appeal next addressed Aetna’s inadequate medical and vocational reviews. Specifically, Aetna’s reliance an in-house Transferable Skills Analysis (TSA) was unreasonable because (a) Aetna misstated and mischaracterized Ms. A’s treating physician’s Capabilities and Limitations Worksheet (CLW) and ignored Ms. A’s most recent and relevant medical information; and (b) the TSA relies on these faulty restrictions and limitations to determine Ms. A had sedentary capability. What’s more, the electronic claim notes confirmed that Aetna’s in-house nurse reviewer concluded that Ms. A was “significantly limited in most function” and she was “on pain medications that may cause side effects” and that “her ability to perform activities beyond ADLs [i.e., activities of daily living] is questionable.” In sum, the restrictions and limitations assigned to Ms. A by her treatment provider did not, as Aetna suggested, support her ability to perform at a sedentary work level, which was confirmed and supported by Aetna’s own in-house nurse reviewer.

Several months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, the parties agreed to a negotiated financial resolution of Ms. A’s claim. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.