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Court Finds Multiple Errors and Orders Aetna to Pay Claimant Long Term Disability Benefits

In Mendez v. FedEx Express and Aetna, plaintiff Miguel Mendez had worked 28 years as a delivery driver for FedEx when he was severely injured in a car wreck. He suffered a traumatic brain injury (TBI), a splintered pelvis and multiple other orthopedic injuries. Aetna, plan administrator for FedEx, initially granted Mendez’s application for disability benefits.

Since Mendez was unable to work in his own occupation as a delivery driver, he received disability benefits for 24 months according to the provisions of his disability insurance. After that time, he was required to prove he was totally disabled in order to continue receiving disability benefits. Meanwhile, at Aetna’s insistence, Mendez applied for and was awarded Social Security Disability benefits. Aetna collected a portion of those benefit payments as an offset to its own payments to Mendez.

Ultimately, Aetna decided that Mendez was not totally disabled so not eligible for long term disability payments. After he exhausted his administrative appeals, Mendez filed this ERISA lawsuit. After review, the District Court found in favor of Mendez, holding that “Mendez was denied benefits to which he is clearly entitled. Thus, rather than remanding, Aetna is ordered to pay Mendez the long-term disability benefits for which he is qualified under the Total Disability definition of the plan.”

Three Errors Made by Aetna in Denying Long-term Disability Benefits

In making its decision that Aetna acted in an arbitrary and capricious manner in denying long-term benefits to Mendez, the Court found Aetna made three specific errors.

· Aetna relied on opinions of medical professionals who did a paper review of the files. No one conducted an in-person, face-to-face examination. The law allows insurers to rely on the opinions of file reviewers, even if they conflict with the report of treating physicians. But, in this case, these reviewers “disregarded the extensive complaints of severe pain recognized by Mendez’s treating physicians.” Instead, even though Aetna acknowledged his extensive injuries, it denied him benefits without even examining him.

· The Court found that the reviewing physicians had a conflict of interest and were “repeat players that have a material, if not necessarily disabling conflict of interest.” This factor alone does not automatically render Aetna’s opinion arbitrary and capricious.” But, it “is a factor that weighs against it.”

· Aetna did not “adequately explain” why it was ignoring the Social Security Administration’s award of benefits to Mendez. Aetna simply stated, that the Social Security Administration used different criteria than Aetna did in evaluating disability claims. This was not enough, particularly when Aetna:

· 1) encouraged Mendez to apply for SS disability payments;

· 2) benefited financially from his award of SS disability benefits; and,

· 3) failed to explain why its position was different than the SSA.

Based on all these reasons, the Court found that Aetna’s decision to deny Mendez long-term disability benefits was arbitrary and capricious.

No Need for Remand When Claimant is Clearly Entitled to Benefits

The Court noted that when there is a problem with the “integrity of the plan’s decision making process” the remedy is to remand to the plan administrator. “When the objective medical evidence clearly establishes that the claimant ‘was denied benefits to which he is clearly entitled’ the Court may award benefits without remanding.” The court then listed Mendez’s multiple medical issues, the many medications he was taking and his treating physicians statements that Mendez could not stand for more than 30 minutes or sit for one hour, has balance problems and limited tolerance for ambulation and concluded that he was clearly entitled to disability benefits and remand “would be a useless formality.”

This case was not handled by our office, but we think it can be helpful to those who are struggling with their insurer on evidence sufficient to prove they are totally disabled. If you have any questions about this, or have any other problems with issues surrounding your disability benefits, contact one of our disability attorneys at Dell & Schaefer.

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Can you help with a Aetna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Aetna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Aetna.

How do you help Aetna claimants?

Our lawyers help individuals that have either purchased a Aetna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Aetna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

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I was in a difficult situation dealing with a disability claim. Once I spoke with Stephen Jessup, that ball started rolling and progress was made. He and his assistant Sonia made a point to stay in contact and made it very simple for me to keep them aware of my status as time passed.

I have a lot of legal experience and Stephen and Sonia treated me with respect, and talked honest and openly with me throughout the conclusion of my claim.

I would strongly recommend using Stephen Jessup to anyone who needs help. It would have been very difficult to have fought for my rights alone.

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