Aetna Overturns Denial of Long Term Disability Benefits for Quality Control Manager

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.

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FAQ

Do you help Aetna claimants nationwide?

We represent Aetna clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Aetna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Aetna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Aetna.

How do you help Aetna claimants?

Our lawyers help individuals that have either purchased a Aetna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Aetna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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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.

What are your fees?

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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Dell & Schaefer Client Reviews   *****

Craig S. (Texas)

I have been extremely impressed with the Law Firm of Dell & Schaefer.

I submitted a form online and was contacted immediately by Mr. Jay Symonds. I explained my disability and the issues I was experiencing with my Long Term Disability Insurance and Mr. Symonds immediately confirmed why Dell & Schaefer was the perfect choice for me.
I explained my situation and what I had experienced with LTD and Mr. Symonds immediately shared with me what he could do for me and for the first time in months, I felt at ease with what I was going through.

Mr. Symonds immediately contacted the insurance company and was able to achieve in 1 day what I hadn’t been able to achieve in Months!

To say that Mr. Symonds was my guardian angel would be an understatement. His knowledge and expertise enabled me to focus on the treatment that I needed.

His staff was always very friendly and my questions were always answered in a timely manner. Throughout this journey, Mr. Symonds and his staff have become like family to me with their support and compassion. Mr. Symonds and Sonia Nogueira have shown empathy, respect and concern for my medical condition.

It was refreshing to see my team of legal experts take immediate action when the insurance company continued to try and bypass the process. I could not have found a better team to represent me and I will always be thankful for their knowledge and expertise.

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