Aetna Overturns Denial of Long Term Disability Benefits to Bank Manager with Multiple Sclerosis Following ERISA Appeal
Author: Attorney Stephen Jessup
Our client was a former credit manager for a large banking institution who was suffering with Multiple Sclerosis. Despite his best efforts to continue to work through his continually worsening symptoms, he finally succumbed to the multiple effects of MS and filed for short term and long term disability benefits with Aetna. Aetna initially approved his claim for short term disability benefits based upon the medical records forwarded from his doctors. However, when his claim was to convert to long term disability, Aetna determined that the records that had supported his claim for short term disability benefits somehow no longer supported his claim for long term disability benefits.
Why Would Aetna Deny Benefits For Long Term Disability Benefits Based On Medical Records It Had Used To Approve Short Term Disability Benefits?
Like many employer provided disability policies, the short term disability policy is often funded by the employer, which means it is the insured’s former company that is responsible for penning the check. However, more often than not when the claim becomes one for long term disability benefits the funds that pay the benefit comes out of the assets of the insurance company. Essentially, when an insurance company is footing the bill, it is not surprising when they no longer feel that the medical records that supported short term disability no longer support long term disability.
Diagnosis Does Not Equal Disability According to Aetna
Aetna denied our client’s long term disability claim based on what it considered to be a lack of objective medical evidence to support physical restrictions and limitations that would result in the inability to work. Essentially, Aetna was claiming that although our client had Multiple Sclerosis, there was not enough documentation to support that he was prevented from performing the duties of his job. This is a very comment argument that insurance companies use when evaluating claims for mental health or pain conditions that is now being seen with somewhat more frequency as it relates to Multiple Sclerosis. It is the duty of the claimant to provide the requisite information to draw the nexus between diagnosis and disability.
The ERISA Appeal For Long Term Disability Benefits Against Aetna
Following his denial of long term disability benefits, our client contacted Dell & Schaefer to assist him in the filing of his administrative appeal. Attorney Stephen Jessup was assigned to his case and quickly set out to develop a plan of attack to provide adequate documentation to counter each of Aetna’s reasons for denying the claim. Understanding the strategy employed by Aetna, Attorney Jessup coordinated testing to document the physical and cognitive limitations that were preventing our client from working; reviewed all of our client’s medical records; and contacted our client’s treatment providers to complete specifically crafted questionnaires that addressed Aetna’s position that our client was not prevented from working in his occupation. Attorney Jessup then correlated the findings of the preceding to unequivocally prove that our client could not work in his former capacity. Following the submission of the appeal, Aetna overturned its denial of benefits, reinstated our client’s claim and forwarded all back benefit checks.
Proving Disability Is Not An Easy Burden
Under ERISA based disability policies, it is the responsibility of the insured to prove disability. A diagnosis of a medical condition is not sufficient to satisfy the terms and conditions of most disability policies. The nexus between the condition and how it affects one’s ability to work must be sufficiently established if one hopes to have their claim approved. If your claim has been denied and you need assistance in filing your ERISA appeal or lawsuit, then please contact Attorneys Dell & Schaefer for a free consultation.