Aetna’s denial of disability benefits for human resource generalist is upheld after claimant’s definition of disability changes from “own occupation” to “any occupation”

Ms. Mote was injured in a car accident in August 1997, and stopped working for Arthur Anderson as a Human Resource Generalist on April 10, 1998, because of her back pain and fibromyalgia. She applied for long-term disability benefits provided by Arthur Anderson through Aetna, and began receiving benefits on July 10, 1998.

After receiving benefits for five years, Aetna discontinued disability benefits on December 8, 2003, claiming that Ms. Mote no longer met the definition of total disability under the own occupation definition of total disability. To support its decision, Aetna reviewed Ms. Mote’s treating physicians’ notes, MRIs, CT scans, surgical procedures, and statements from her doctors. Aetna also hired an investigator who had videotaped Ms. Mote engaged in activities that she claimed she was unable to perform. Additionally, Aetna performed a functional capacity evaluation (FCE) on November 11, 2002, and an independent medical exam (IME) on September 15, 2003. Both of these reports indicated that Ms. Mote could perform a sedentary occupation. Aetna’s two consulting physicians also reached the same conclusion after reviewing the available medical records.

In requesting that Aetna review their decision to deny Ms. Mote’s claim for long-term disability benefits, she submitted additional medical records and statements from her treating physicians, all of whom supported her disability benefits claim. Aetna submitted Ms. Mote’s entire file, including the additional records, to an independent medical review performed by Dr. Hall, hired by Aetna. This file included the disability surveillance video of Ms. Mote.

After reviewing the video, Dr. Hall concluded that he did not agree with the limitations and restrictions imposed by Ms. Mote’s treating physicians, and saw no reason why Ms. Mote could not work in a light capacity without restrictions. Aetna wrote a letter to Ms. Mote on September 28, 2004, upholding the denial of her long-term disability benefits. Ms. Mote then filed suit.

Ms. Mote argued that there was no evidence that her condition improved. However, the trial court agreed with Aetna’s argument that her disability benefits were discontinued because she did not meet the new definition of total disability that came into effect after receiving five years of benefits, not that she was not still disabled under the any occupation of total disability. Specifically, the definition of Total Disability in the disability policy stated:

that solely because of an illness, pregnancy or accidental bodily injury, an insured employee is unable: (1) [d]uring the first 5 years of disability to perform the material duties of the employee’s own occupation; and (2) [f]rom then on, to work at any occupation for which such employee is, or may reasonably become, fitted by education, training or experience. The availability of employment will not be considered in the assessment of the employee’s disability.

The court also agreed that Aetna’s decision to deny benefits was reasonable in light of all the evidence available, specifically the surveillance video directly contradicting the restrictions and limitations imposed by Ms. Mote’s treating physicians. The court also noted that even though Ms. Mote was receiving Social Security Disability Insurance (SSDI), Aetna did not act unreasonably because the definition of disability for each plan was different.

See Mote v. Aetna Life Ins. Co., No. 06-4127, 2007 U.S. App. LEXIS 21825 (7th Cir. September 12, 2007).

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