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

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.

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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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Reviews

Bruce R. (Arizona)

Steve Dell has done an exceptional job with my disability application process. The firm is extremely well managed. They have acquired an incredible amount of experience over many years. I recommend them for disability insurance claims without reservation. 

Don (Florida)

I called this firm a few months ago completely disparaged due to a company cutting off disability benefits at a time that nearly caused me to lose everything.

Attorney Alex Palmera and Danielle worked hard to reach an amicable settlement and my case was settled a few months later. This is a good firm and the specific expertise in disability claims saved me countless hours of hassle at a time when an already fragile state existed.

Thank you Mr. Palamara and Danielle.

Sandra B. (Arkansas)

I have nothing but good things to say about how my buyout was handled with my disability claim. The level of professionalism was amazing. All of my questions and concerns were answered either by Danielle L. or Alex P. in such a timely manner and with such care I would recommend them in a heartbeat to anyone needing to approach their provider with buyout options.

They did a fantastic job communicating between the provider and me, always keeping my best interest at heart and always answering my many many questions. They really did take most of the stress out of this whole situation. I would give them a 10 out of 10 for every step of this crazy journey. Thank you so much for helping me through this.

Brenda R. (New York)

I needed assistance with an appeal for a LTD claim that was initially denied. Stephen understood what needed to happen to win the appeal and he did win the appeal for me.

Michael C. (Virginia)

Greg Dell and his assistant Anneli have been extremely responsive and helpful, not only our initial consultations, but in follow-ups 1 and 2 years later with the insurance company to ensure that they comply with their agreements (which they did), as well as a separate and only slightly-related inquiry about our health insurance. I always hear back from them very quickly, which is rare and greatly appreciated.

Jeff P. (Oklahoma)

After a very long and frustrating ordeal to keep my LTD payments coming I decided to seek assistance from and attorney. After much research and asking those in the legal profession Dell & Schaefer seemed to be the top choice. I reached out and Alex Palamara was the attorney assigned to my case. All I can say is the experience was outstanding. Both Alex and his Paralegal, Danielle Lauria were excellent to work with. They were very kind, concerned, understanding of my frustrations and treated me with the utmost respect. Communication was excellent with regular updates and telling me what I could expect in each stage of the process.

Alex was also very straight forward with what to expect and no pie in the sky promises or expectations were made. In the end we won our case and I believe it was solely due to their experience and knowledge of not only the laws but the insurance companies as a whole. I would highly recommend them and am very grateful for the help they afforded to me.

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