Aetna overturns decision to deny LTD benefits for claimant suffering from post-concussion syndrome and neurocognitive disorder
Author: Attorney Rachel Alters
The above claimant contacted the law firm of Dell & Schaefer to represent her after receiving a denial of STD and LTD benefits from Aetna. In its denial letter, Aetna states that its decisions to terminate her STD benefits and deny her claim for LTD benefits was based on the determination that the medical records did not support a functional impairment from performing the material duties of her own occupation as an Senior Software Developer. After reviewing all of her medical records, her claim file and speaking with her treating physicians, Attorney Alters determined that Aetna failed to provide her with a full and fair review of her claim. Aetna dismissed the overwhelming volume of objective evidence supporting her claim for total disability, such as; significant abnormal findings on objective diagnostic testing, credible complaints of cognitive dysfunction, and clear observed limitations by her board certified physicians and specialists. The medical and occupational documentation clearly established that due to physical limitation resulting from post-concussion syndrome, static encephalopathy, hypothyroidism, dementia due to traumatic brain injury, memory impairment, anxiety due to medical condition, panic disorder, and depressive disorder due to medical condition, the claimant was unable to perform with reasonable continuity the material duties of her own occupation.
Aetna Cherry Picks Medical Records to Support Denial
There is no question that Aetna cherry picked medical records in an attempt to show that the claimant was no longer disabled. Aetna relied on an Attending Physician Statement by the claimant’s treating physician which stated that she was unable to work due to hypothyroidism. In an office visit noted dated 1/28/2014 her doctor noted that she was feeling a lot better, had more energy and was less tired and irritable. In an office visit noted dated 3/6/2014, her doctor noted that she was feeling better over the past month, had increased concentration and her mind was less foggy.
However, upon reviewing her complete medical records, contrary to Aetna’s determination, there was no indication from any of her treating physicians that her medical condition had actually improved. All of her treating physicians continued to document ongoing symptoms and continued impairment which prevented her from returning to work, in either her own occupation or in any occupation. Though the office visit notes in January and March 2014 mention that the claimant experienced some improvement with improved energy, feeling less tired, less depressed, and increased concentration, at those same office visits she noted continued concentration difficulties, slower processing, decreased self-confidence which leads to increased anxiety. In the subsequent office visits, her doctor notes continued forgetfulness, decreased concentration, increased stress, explosive outbursts, impulsivity, difficulty focusing, and ongoing medication adjustments. Aetna ignored all of these findings as well as her treating physicians’ opinions that she suffered from incapacitating symptoms which entirely precluded her ability to perform both the material duties her own occupation, as well as the duties of any reasonable occupation.
Neuropsychological Evaluation Demonstrates Claimant is Not Capable of Working in Her Occupation
The Claimant underwent a thorough neuropsychological evaluation to determine whether she had the ability to work. A neuropsychological examination is indicative of cognitive impairments in the areas of sustained mental control, visual memory, capacity for new learning, and problem-solving under timed conditions. After performing a lengthy evaluation, the neuropsychologist found that she was not capable of performing the reasonable and customary occupational duties of a Software Application Designer. Her prognosis for recovery was poor given her status at this time post-injury.
After reviewing Attorney Alters appeal which included updated medical records, physician opinions and neuropsychological testing, Aetna overturned its decision to terminate her benefits, paid her past benefits an put her back on claim. Attorney Alters will continue to manage her claim to help ensure she continues to receive her monthly benefits.