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Aetna Ordered to Produce Internal Statements of Policies, Procedures and Guideline Relative to Claimant’s Long-Term Disability Claim

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Prior to ceasing work due to her disability, Ms. S was employed as a service center organizer for Boston Building Service. Her duties included providing worker support during the grievance process with the union, and field support various union related issues. In December 2008, Ms. S was forced to stop working and file for disability insurance benefits due to chronic knee and back pain. Ms. S also suffered from hypertension, gastro esophageal reflux disease, hypothyroidism, obesity, depression and anxiety.

Aetna approved Ms. S’s claim for disability benefits through the entire 26 week short-term disability period, and paid long-term disability benefits through June 2011. During this time, Aetna even hired a third-party firm, Allsup, to represent Ms. S in her claim for social security disability benefits. By hiring Allsup to represent Ms. S in her social security disability claim, it increased the chances that Ms. S’s benefits would be approved, while also reducing the amount of disability benefits it would pay Ms. S, since the disability plans allowed Aetna to offset any social security disability benefits received from Ms. S’s monthly disability benefit.

Aetna Continues to Deny Disability Claim Through All Administrative Appeal Levels Despite Finding of Total Disability By Social Security Administration

Ms. S appealed the denial of long term disability benefits with Aetna. As part of her appeal Ms S submitted further evidence supporting that she remained disabled from her own occupation and any gainful occupation, as well as evidence that she met the Social Security Administration’s stringent standard of total disability; however, Aetna continued to uphold its decision to deny benefits.

Federal Court Orders Aetna to Produce Internal Statements of Policies, Procedures and Guidelines

Having exhausted all of the administrative appeals available under the long-term disability plan, Ms. S filed suit in the US District Court for Massachusetts. This claim was not handled by our law firm. Generally, ERISA lawsuits for denial of disability benefits are adjudicated on the administrative record compiled before the Plan Administrator. See Denmark v. Liberty Life Assur. Co., 566 F3d 1,10 (1st Cir. 2010). This means that the judge typically has to adjudicate the case solely on the administrative record created during the course of the insurance claim, and cannot consider any evidence not in the administrative record at the time the final decision to deny benefits is issued. This extremely limits the ability for the insured’s attorney to conduct discovery during the course of litigation.

However, Federal Courts typically allow some limited discovery into conflict of interest, as well as discovery of the administrator’s internal guidelines, plans and training manuals. Ms. S’s attorneys requested that Aetna produce internal statement of its policies, procedures and guidelines. Aetna objected to the request on the grounds that the documents were outside of the administrative record and not subject to discovery. After hearing arguments from both Ms. S and Aetna, the US District Court for Massachusetts ordered Aetna to produce its internal guidelines, policies, procedures, and training materials that were in effect at the time of claim denial.

If your claim has been denied by Aetna or you need assistance with any disability insurance claim, then contact any of our disability insurance attorneys for a free consultation.



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