Prior to enlisting our services to challenge a denial, our client had received benefits from Aetna due to his disabling conditions for 18 months. Unfortunately for our client, Aetna decided to deny benefits due to the “change in definition of disability.”
Common in most group disability insurance policies, the change in definition typically happens after benefits have been paid for 18 or 24 months. For the initial 18 months, in order to be considered disabled, this former Sales Associate had to merely prove that he could not perform the material duties of his own occupation. After the 18 month mark, the former Home Depot employee then had to prove that he was unable to work at any reasonable occupation. A reasonable occupation is one which a claimant is fitted for by their education, training or experience and one which would pay 60% or more of the claimant’s pre disability earnings.
Unfortunately for our client, on the exact day that the change in definition of disability occurred, Aetna made the determination that he did not satisfy the new definition of disability and Aetna denied benefits. Although our client suffered from a host of disabling conditions which included migraines, fatigue, lumbar radicular pain, sciatica, leg ulcers, osteoarthritis, cervical issues, diabetes, kidney disease, fibromyalgia, etc., Aetna remarkably believed he no longer satisfied the new definition of disability.
In support of its decision to deny benefits, Aetna relied up on the report of a Peer Reviewer who never met with or evaluated the claimant but who concluded that he would be “capable of working a full time sedentary job.” This reviewer also concluded that he was “not functionally impaired based on the medication documentation.”
Review of the Record:
After speaking with the claimant, Attorney Alexander Palamara agreed to take on this claim and assist the claimant with an appeal to challenge the denial. The first thing Attorney Palamara realized is that Aetna’s conclusion that the claimant was “not functionally impaired” was laughable. A quick review of the recent medical documentation showed clear objective evidence that our now client suffered from various medical conditions that left him with severe restrictions and limitations. Objective evidence included multiple MRI’s of the brain that revealed white matter changes, very high blood pressure readings, multiple falls due to impaired balance, impaired sensation, ulcers, positive x-rays of the knees, and decreased range of motion.
Appeal by Attorney Palamara:
An appeal was filed by Attorney Alexander Palamara. The appeal initially cited many issues with Aetna’s reviewing doctor’s report and the fact that it overlooked objective evidence which supported the claim. Beyond fighting the review, the appeal also focused on the evidence in the file and the great support from each of the treating providers who each essentially stated that the claim was “not able to work.”
The appeal also noted that in 2017 alone our client had “been seen 11 times by his doctor, spoken to his physician 12 times, corresponded via email 8 times, been seen in the Emergency Room 5 times, had 1 inpatient hospitalization, 3 urgent care appointments, 3 visits to the GI clinic, 1 visit in neurology, 4 visits in urology, 5 times seen by his psychiatrist and also been seen by several medical professionals in Columbus, Ohio.”
The appeal concluded that Aetna’s decision had to be overturned due to the overwhelming evidence which supported no other conclusion but to find our client disabled under the new definition of disability.
Claim Re- Approval:
On December 20, 2018, we received word that Aetna had decided to overturn its decision to deny benefits for the period of March 15, 2018 through October 25, 2018. Aetna had agreed to pay benefits for that time period as it continued its review for benefits beyond October of 2018. However, at the same time we received word that the claim had been reapproved for that short period of time, we submitted updated records and a Notice of Award from the Social Security Administration which showed that Social Security had now concluded that our client was also disabled. On December 31, 2018, Aetna informed us that it had determined that our client now meet the definition of being totally disabled from any occupation and agreed to reinstate continued benefits.
Our client is happy to get his re-approval and knows that we will continue to fight to get him all the additional benefits he is owed. He knows that Dell & Schaefer will always do whatever it takes to get him his deserved benefits. If you have been denied disability benefits by Aetna or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.