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Court Finds Aetna Had No Credible Argument Whatsoever To Support Its Decision To Deny Benefits To Claimant With MS



Attorney Victor PeñaAuthor: Attorney Victor Peña

When it comes to ERISA governed claims, no circuit is more plaintiff friendly than the 9th Circuit. A recent ruling by a Washington district court reminds us of that although the behavior by the disability insurer, Aetna Life Insurance Co., in Gorena v. Aetna deserved a strong reprimand.

Ms. Gorena worked as a staff analysist for Boeing for more than 10 years before leaving work due to her worsening multiple sclerosis. She had been diagnosed 8 years before seeking disability benefits and her treating neurologist was a well-known MS researcher.

In denying Ms. Gorena’s claim, Aetna relied on its reviewing medical consultant who found no evidence of functional capacity. The court overturned this determination and in the process expressed deep concern about Aetna’s treatment of the case.

The evidence in support of Ms. Gorena’s disability claim was comprised of years of records including 10 MRIs, 14 psychological reports, and 16 attending physician statements all confirming her inability to work. Despite the overwhelming evidence, Aetna’s medical consultant cherry-picked every phrase or detail from the materials that was indicative of some aspect of Ms. Gorena’s condition that was “stable” or “normal.”

The court pointed out that Aetna had totally disregarded a functional assessment completed by the treating neurologist that found, unequivocally, that Ms. Gorena could not stand or sit for sufficient time in an 8 hour work day as a result of her fatigue and cognitive limitations. The court was also disturbed by Aetna’s refusal to consider Ms. Gorena’s subjective complaints without giving any basis for questioning those reports.

In the end, the court found the objective weight of the treating doctor’s records and reports was greater than the evidence relied upon by Aetna. In reaching this decision it cited several factors including the treating doctor’s credibility and reliability in addition to his credentials which included a 20-year history of MS-related research and teaching.

The court overturned Aetna’s decision but took it even further pursuant to a provision of 29 U.S.C. § 1132(a)(1)(B), which allows a plan participant to sue to “clarify [its] rights to future benefits under the terms of the plan.” The court determined that Ms. Gorena had proved her disability under the own occupation as well as any occupation standards in her policy and that benefits were to continue “unless Aetna can establish that [Ms. Gorena] is capable of performing such work productively, full-time, and without undue disruptions and/or absences due to her MS and its related symptoms, she is to continue to receive LTD benefits to the Plan’s maximum duration.”

There is no question the court was offended by Aetna’s conduct in this case. Most courts would not have addressed future benefits but Aetna’s conduct was so egregious that the court felt the need to do so.

This case was not handled by our office, but we think it can be beneficial to those struggling to obtain long-term disability benefits. If you have any questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free case evaluation.