In my opinion Aetna’s handling of our client’s long term disability claim is egregious and unreasonable. We share this story with you in order to continuously educate the public about the conduct of many disability insurance companies.
My client suffers from fibromyalgia, depression, and multiple other conditions. She has been receiving benefits from Aetna for two years and her definition of disability recently changed from own occupation to any occupation. Aetna has requested an “Independent Medical Exam” in order to have her examined by a doctor of Aetna’s choice. While Aetna refers to the exam as an Independent Medical Exam (“IME”) the correct name is a Compulsory Medical Exam (“CME”) as the policy requires our client to appear at the exam. Our client has agreed to go to the CME, yet she requested to have the examination either videotaped, tape recorded, or have an independent witness appear with her. Aetna denied the request for video or an audio recording device and stated in writing, “To ensure an independent evaluation no video or recording devices and no presence of person other than the examinee.”
We sent Aetna a letter in response and stated:
“You have stated the following in your letter which does not appear anywhere in the long term disability plan language:
To ensure an independent evaluation, the following conditions must be observed:
- No video or audio recording devices.
- No presence of persons other than the examinee. No children. No attorneys. An exception will be made for an independent interpreter in cases where there is a known langage barrier.
With all due respect it simply does not make sense to state that prohibiting a video or audio device will “ensure an independent evaluation”. There is nothing more accurate than a videotape recording of every single thing that takes place during the examination that AETNA is requiring. In order to verify accuracy all lottery drawings are videotaped, United States congressional sessions, and most law enforcement interrogations. Certainly videotaping has been proven as a method of accuracy. The act of refusing to allow the videotaping of a CME exam requested by an insurance company is unreasonable and unfair to all plan participants. If you are concerned somehow about the accuracy of the video recording, we have no problem if Aetna hires the videoagrapher that will attend the examination. We have no problem with AETNA, the examining doctor and the claimant all receiving a copy of the videotape. Furthermore, if AETNA believes the cost of the video is a problem, then our client will pay for it. AETNA has a fiduciary duty to act in the best interest of its plan participants and a video tape of the exam is the number one method to maintain independence and validity in a CME.”
Aetna’s responded by stating they are not allowing the exam to be video recorded and if your client does not go to the IME exam with Dr. Stephen Demeter then we will deny her benefits. We further advised Aetna of Dr. Detemer’s reputation for conducting more than a thousand IME exams for disability insurance companies and his affiliation with the Reed Group as a member if it’s medical advisory board. The Reed Group advertises themselves as “The World’s Most Trusted Return to Work Experts.”. In my opinion this means, hire the Reed Group and we will find a doctor that will usually say that the claimant is not disabled.
In anticipation of the CME exam with Dr. Demeter we contacted the office of Dr. Demeter and asked if they had any forms they wanted our client to fill out before she arrives. We reviewed the multiple pages Dr. Demeter requested, and one of them was a document titled Individual Patient’s Authorization. We reviewed Authorization with our client and we found it be poorly drafted and almost impossible to understand. Our client had already signed numerous authorizations allowing Dr. Demeter and Aetna to review all of her medical and occupational records. It is highly unusual for an IME doctor to have a disability claimant sign a generic authorization form. Stephen Scott, the Aetna Claims Analyst called our office today and said that our client must sign the form or Dr. Demeter won’t exam her. He then said that if Dr. Demeter does not exam her, then her benefits will be denied. I asked Mr. Scott to explain the form to me and he was unable to do so. I asked Mr. Scott to take the form into his supervisor’s office and have him explain it to me, but Mr. Scott stated that he was at home and he could not meet with the supervisor. I hung up with Mr. Scott and sent him the email listed below.
From: Gregory Dell
Sent: Wednesday, December 15, 2010 5:12 PM
To: ‘firstname.lastname@example.org‘; ‘email@example.com‘
Cc: Anneli DeCardenas
Subject: IME WITH DR. DEMETER at Honolulu Sports Medical inc.
Thank you for calling me about the document titled INDIVIDUAL PATIENT’s AUTHORIZATION that Dr. Demeter’s office is requiring Ms. Rose to sign. I have advised you that my client and I do not understand the form and have asked for clarification. I have asked you to explain the form to me and you were not able to. You advised me that if Ms. Rose does not sign the form then the doctor will not examine her and you will stop her benefits. How could my client possible pay any of her bills if you decide to cut her benefits for failure to sign a form that cannot be understood. You have once again left my client with no options as she cannot afford to have her long term disability benefits stopped by Aetna. As such she will have to sign a release form which make absolutely no sense and appears to not be HIPPA compliant. I have asked you to contact your supervisor and see if he understands it. Unfortunately this disability claim is governed by ERISA and I cannot immediately go to the court to prevent you from denying disability benefits. As such, AETNA continues to hold the gun to my client’s head and she will have to sign a document which neither myself or her understand. You should not forget that AETNA has already prohibited our client from videotaping the exam, recording the exam, or bringing an independent witness to attend the exam. I have advised you that my client has no objection to Dr. Demeter reviewing all of her records, but it is outrageous for her to be required to sign an authorization form that no reasonable person would understand. I have already advised you that Dr. Demeter and Honolulu Sports Medical Inc. have performed thousands of IME exam, so I am surprised that they would be requiring people to sign a generic release form that cannot be understood. Certainly Dr. Demeter could use some of the proceeds from his thousands of IME exams to draft an authorization form that is written in plain English. My client will be at the Compulsory Medical Exam and she will sign the form under duress as Aetna has given her no other option. We look forward to receiving a copy of the report upon completion.
Gregory Michael Dell, Esq.
Attorneys Dell & Schaefer Chartered
The Aetna Supervisor called me about 30 minutes later and basically said the form needs to be signed so that Dr. Demeter can send the report he completes to Aetna. I advised Aetna that the form clearly did not state what he thought it said. The Aetna supervisor said there is nothing we can do and she must go to the exam. I advised the supervisor that my client will be at the exam and she will sign the form as Aetna has threatened to stop paying her benefits if she does not sign it. The supervisor and the claims examiner basically had the same attitude, which was we don’t care and we will talk to you after we get the report back from our hired gun doctor.
The outcome of this scenario will hopefully be that Dr. Demeter determines our client has restrictions and limitations, which will require Aetna to continue to pay her disability benefits. I am skeptical about the outcome of Dr. Demeter’s opinion as the last IME exam at Honolulu Sports Medical Inc., was with Dr. Peter Diamond. Dr. Peter Diamond and Dr. Stephen Demeter work at the same office. In a previous disability claim, Dr. Peter Diamond was hired by Prudential Insurance Company to conduct an IME exam and he found that our client was not disabled. A Hawaii federal judge subsequently disagreed with Dr. Diamond’s findings and reversed Prudential’s denial of disability benefits.