After Aetna denied Ms. Garner’s long-term disability claim, Ms. Garner filed suit against Aetna, and the Court overturned Aetna’s decision and ordered it to pay Ms. Garner’s disability benefits
Author: Attorney Cesar Gavidia
In 2004, Sally took a leave of absence from her job as an import supervisor for a global shipping company to undergo surgery for an internal left knee derangement. During that time she had also been suffering from severe symptoms of depression following her son’s departure to college and the at-home environment changing. Her doctors diagnosed her with bipolar disorder II and placed her on depression and anxiety medications.
Sally promptly filed claims under her private long-term disability insurance with Unum Life Insurance Company and her group long-term disability insurer, Aetna Life Insurance Company. Unum approved her long-term disability claim and began issuing disability benefits following the 90 day elimination period. Aetna also approved her short-term disability claim; however, after 180 days, at the point that her short-term disability claim was to pass into her long-term claim, it notified Sally that her benefits were being terminated.
Shortly after she had stopped working, Sally underwent knee surgery and began physical therapy with the hopes of recovering and returning to work. However, her pain persisted after surgery, which increased her sadness and hopes of once again living a pain free normal life. Adding insult to injury she also now faced having to appeal Aetna’s erroneous decision to deny her long-term disability benefits, despite her doctor advising her physical disability were permanent and would never improve to where Sally would be capable of returning to sedentary employment.
Sally and her husband met with Attorney Cesar Gavidia to discuss their options relating to Aetna’s denial of her claim. In its denial letter, Aetna claimed that Sally was no longer disabled for failing to submit sufficient proof of loss, and that it had not received sufficient information to support restrictions and limitations. Aetna informed Sally that if she disagreed with the decision she could appeal the decision within 180 days.
Attorney Gavidia prepared Sally’s Appeal addressing both her physical and mental limitations. It was important to establish that Sally’s physical limitations were the primary cause of her disability, and aggravated her long-standing mental health issues. However, by themselves, her physical conditions caused her to be totally disabled. After receiving the Appeal Aetna overturned its decision and reinstated Sally’s disability claim.
For the next 13 years, Sally received long-term disability benefits with the help of Attorney Gavidia. He navigated her claim through the transition from Own Occupation to Any Gainful Occupation, after she had received benefits for 24 months. He managed every aspect of her claim including the completion and submission of claim forms and attending physician forms, and was the only point of communication for Aetna, so that they could not reach out directly to Sally to coerce into statements that could jeopardize her right to receive her disability benefits.
In 2018, 13 years after Attorney Gavidia had successfully appealed her disability claim, Sally reached age 65 and the maximum benefit period under her Aetna Group Long-term Disability Policy. Please call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.