Aetna Reinstates Benefits for Former SAP America Employee Suffering the Effects of a Head Injury
Author: Attorney Alex Palamara
My now client worked for SAP America, Inc. as a Senior Solutions Sales Executive for nearly seven years. She made a great salary working at a job and employer she loved. Her work required superior cognitive and analytical skills and was both challenging and rewarding. Unfortunately for her, in December of 2016, she suffered a serious head injury. While she attempted to remain working, as of January 2017 her symptoms of headaches, dizziness, memory lapses and nausea proved too much. This was after all, her 5th concussion dating back to her childhood. Fortunately for her, her employer provided its employees with coverage under a Long Term Disability Insurance policy and this policy was thankfully with Aetna Life Insurance Company.
Claim Initially Approved and Then Denied
After our client applied for benefits under the LTD policy, Aetna initially approved the claim and benefits effectively began in July of 2017. Aetna had thus concluded that she was unable to perform the material duties of her own occupation. However, Aetna was not approving her claim due to her brain injuries; Aetna was merely approving her claim as it believed that she may be impacted psychologically. Giving credit to Aetna, although they stated they found no support for cognitive impairment, they approved her claim as they wanted to allow her time to get in appropriate treatment for any psychological condition she may have been suffering from. This is unique and Aetna should be commended for the actions it took initially with this claim.
While its overlooked documentation regarding the claimant’s brain jury, it acted in good faith and paid benefits while allowing the claimant time to gather additional support for her claim.
Unfortunately for our client, her approved status changed in March 2018 when Aetna then determined that she did not meet the definition of disability. Aetna pointed to the fact medical documentation in support of any psychological impairment was not provided and that it concluded that a review of other medical documentation was insufficient to show any functional impairment. Aetna believed that “physical exams and diagnostic findings” were “unremarkable” and there was “a lack of supporting documentation to provide functional limitations from a physical or mental health perspective that would prevent (her) from performing (her) own occupation…”.
Client Finds Attorney Alexander Palamara of Dell & Schaefer
Knowing Aetna’s decision to be wrong, the claimant found our firm and contacted us immediately after receiving the denial letter. After speaking with the claimant and reviewing the denial letter, it was easy to see that Aetna’s denial was incorrect. The claim file was immediately ordered from Aetna. Additionally, all medical records pertinent to this claim were ordered from each of our client’s treating providers. Such documentation included the report of a Neuropsychological Evaluation conducted in September 2017 as well as reports from physical examinations and other diagnostic testing. In addition to a gathering of all supportive medical records, Attorney Palamara arranged for an independent review of our client’s medical records by a board certified internal medicine and primary care sports medicine physician who specializes in the treatment of Traumatic Brain Injuries.
An appeal was timely filed. The appeal pointed to the supportive medical documentation, outlining everything Aetna seemingly overlooked. The appeal also pointed to the history of support from the treating providers. The appeal then pointed to the extensive and intricate requirements of our client’s occupation. Lastly, our appeal relied upon the findings of the independent reviewing doctor who stated in his report that he “unequivocally opined that (our client) is disabled from her previous job” and pointed to all medical records that supported his conclusion.
Thankfully, our appeal was successful and Aetna overturned its previous denial. Our client is now back on claim and receiving her full monthly benefit. Although she went without benefits, she is thankful to be back on claim. She also is confident that she will remain on claim for as long as she needs to as she knows Attorney Palamara will continue to do whatever it takes to keep her on claim.
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.