Prior to disability our client worked as a Warehouse Distribution Operations Manager for Home Depot, a job that not only required supervision of employees, but a significant amount of physical ability. However, a long fight with uncontrolled diabetes and severe diabetic neuropathy reached a point where he was no longer able to meet the physical demands of his occupation leaving him with little choice but to file a claim for short and long term disability benefits under the Home Deport disability policy with Aetna. Initially, our client did not experience any issues with Aetna- his claim for short term disability was approved and then transitioned to long term disability and in turn approved with no problems. Like the overwhelming majority of Aetna disability policies, his policy contained a 24 month “own occupation” definition of disability. Aetna continued to pay his benefit for the entire 24 month “own occupation” period, but when it came time to review his continued eligibility for benefits under the “any occupation” standard of disability Aetna determined he was no longer disabled under the policy. At that time he contacted our Office and spoke with Attorney Jessup.
In denying our client’s claim for continued benefits Aetna employed a common insurance company tactic – sending information to a treating physician for review and comment and when not hearing back assuming the treating physician is in agreement with the insurance company findings. In this case, Aetna’s reviewing doctor did speak with our client’s doctor and from that conversation unilaterally determined that our client would be capable of “light work” as set forth by the Department of Labor. Aetna’s doctor’s report was then sent to our client’s doctor for comment. When our client’s doctor did not respond, despite there being no confirmation he ever saw the report, Aetna relied solely on its doctor’s opinion that our client could work. In doing so Aetna ignored our client’s long history of medical support from his doctor that he did not have the ability to work in any meaningful capacity due to his severe diabetic neuropathy.
In preparing our client’s appeal Attorney Jessup focused his attention on refuting Aetna’s doctor’s opinion. Of particular note, the findings of the doctor’s report claimed that our client’s conditions were based completely on self-report and lacked any objective evidence to support a claim for disability at any time. This opinion was not only in contrast to the medical records available but also in complete contrast to Aetna’s earlier medical reviews that found our client’s condition would prevent him from working in a meaningful capacity. This alone undermined the credibility of Aetna’s doctor.
Despite being of the opinion our client was not disabled, as noted above Aetna’s doctor determined he would be capable of light duty demand work. Interestingly enough, this was the same physical demand level of our client’s pre-disability occupation. Based on the opinion he could perform light duty work, Aetna had its vocational department conduct an occupational review of our client’s file, which resulted in an opinion that he would be able to perform the duties of his former occupation. Further review of the vocational report and applicable policy language made it clear that based on our client’s education, training and experience the only occupation that would meet the 60% wage requirement for a “reasonable occupation” was in fact his original job. Aetna had essentially done a complete turnaround from its opinion for the previous 24 months that he could not perform his former occupation.
In an effort to properly address our client’s level of physical ability in a work setting, Attorney Jessup arranged for him to undergo a functional capacity examination, the results of which indicated our client’s ability for work fell below a sedentary demand level. Attorney Jessup then gathered additional information in support of ongoing disability to include clarification from his treating physician regarding the conversation he had with Aetna’s doctor and the report sent for his opinion as a result of same.
Aetna Overturns The Denial of Benefits
Upon filing of the appeal, Aetna not only used the allotted 45 days to render a decision, but also exercised its right to 45 day extension to review the appeal submitted by Attorney Jessup. Assuredly, Aetna was trying to find any plausible way to uphold its denial, but the information and argument in Attorney Jessup’s appeal was overwhelming in support of our client’s disability. At the expiration of the 90 day review period, Aetna notified our office that it was reinstating our client’s claim for benefits and forwarding all past due benefits.