Our client, Mr. J, formerly worked as a Quality Control Manager for a large home furnishings store. For many years Mr. J suffered from the debilitating effects of his chronic, organic medical conditions and associated cognitive deficits, including transient cerebral ischemia and chronic migraines, which left him with significant physical and cognitive impairments. As a result of his serious medical conditions and associated restrictions and limitations, Mr. J was forced to stop working in June 2018 and apply for disability benefits under his company’s Long Term Disability (LTD) Policy, which was administered and funded by Aetna.
Aetna Denial of Disability Insurance Benefits
In July 2018 Aetna denied Mr. J’s disability benefit claim. Aetna alleged that the then current medical information received did not support that Mr. J met the definition of total disability – i.e., that he was unable to perform the material duties of his own occupation solely because of an illness or injury. After receiving the denial, Mr. J contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds, who identified several significant issues in Aetna’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. J’s ERISA appeal with the assistance of his appeal team.
The Appeal: Aetna Relied on a Nurse to Review & Deny the Administrative Claim File
The appeal addressed all of Aetna’s short-comings and reasons for denial. First, the appeal addressed the fact that a review of the administrative claim file revealed that Aetna’s purported reviewing “clinician” – on whose opinion the denial was based – was an in-house nurse consultant. Further, it was revealed that this nurse clinician did not have any specialization in neurologic medical conditions and disabilities. In fact, Aetna refused to provide a copy of the nurse clinician’s curriculum vitae and thus it was clear that she lacked the appropriate qualifications to address all of the many co-morbid conditions from which Mr. J suffered. Conversely, all of Mr. J’s physicians – who had evaluated him in person on many occasions over several years – confirmed that he suffered from a host of restrictions and limitations, including among others, severe fatigue, severe headaches, cognitive slowing, word finding problems, essential tremor, right facial paresthesia, generalized weakness, numbness, central vertigo, deafness in the left ear, dizziness, back pain, and joint pain.
The Appeal: The Functional Capacity Evaluation
Next, the appeal detailed the results of a December 2018 Functional Capacity Evaluation (FCE) attended by Mr. J specifically for his appeal. The FCE objectively quantified his maximum physical functional capacity. Mr. J was found to have visible muscle atrophy in the upper and lower extremities. He demonstrated decreased sensation and strength in the upper and lower extremities and exhibited reduced range of motion in his cervical spine as well as his lumbar spine. He was restricted in sitting tolerance and was observed frequently changing positions and needed to stand up during sitting activities to relieve pain in his legs during the intake interview and throughout the evaluation. Mr. J was noted to stumble over his words. In sum, the FCE established that Mr. J had a less than sedentary functional capability based on the totality of all objective testing. As such, Mr. J did not meet the physical requirements of his occupation as a Quality Control Manager and could not perform at a light work functional capacity as required by his occupation. In fact, Aetna failed to consider even one of Mr. J’s material occupational duties in its evaluation of his claim. And in doing so, contradicted the express terms and conditions of the LTD plan.
The Appeal: Updated Attending Physician’s Statement
The appeal also provided an updated Attending Physician’s Statement from Mr. J’s primary treatment provider. The APS established that Mr. J had significant cognitive and functional impairments, notably including the fact that Mr. J suffered headaches more than once daily and lasting more than 24 hours at a time and up to several days. Further, Mr. J suffered associated cognitive dysfunction including problems such as word finding, slurred speech, disturbance of consciousness, memory impairment, attention deficit, concentration deficit, and fatigue. Mr. J’s physician reviewed his job description of Quality Control Manager and confirmed Mr. J would be an unreliable employee at best and confirmed that Mr. J would miss work frequently due to his conditions, and although he may experience good days and bad days, Mr. J could not perform the material duties of his occupation as a Quality Control Manager with reasonable continuity on a regular and sustainable basis.
Finally, it was noted that the record evidence clearly established that Aetna operated under a significant financial conflict of interest in its purported investigation of and determination on Mr. J’s LTD claim. Specifically, it was clear that Mr. J would receive LTD benefits unless, as it did here, Aetna and its paid medical consultant found that Mr. J had full capacity for work. Not surprisingly, Aetna’s determination would have allowed it to avoid a significant financial obligation to Mr. J monthly and for many years to come.
Aetna’s Overturns The Denial
Just 8 weeks after filing his appeal, and after reviewing hundreds of pages of exhibits and medical records, Aetna overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Mr. J’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that Aetna will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation regarding any matter relevant to your disability claim.