Court grants partial summary judgment in favor of Plaintiff, remanding claim back to Aetna to review records it failed to review during the appeals process
Author: Attorney Rachel Alters
In the case of Cannon v. Aetna Life Insurance Company, a Massachusetts Court found that Aetna abused its discretion in denying LTD benefits to a pharmacist with Lyme Disease. The Plaintiff argued that Aetna failed to provide specific documents during the administrative appeal process, such as the entire claim file, which calls into question the integrity of Aetna’s decision to deny his benefits.
Why is Aetna required to provide the complete claim file to a claimant upon request?
Most group disability plans are governed by The Employee Retirement Income Security Act (“ERISA”). This act affords certain rights to claimants who are disabled and claiming rights to benefits under their STD and LTD plans. Specifically, ERISA states: “every employee benefit plan shall afford a reasonable opportunity to any participant whose claim for benefits had been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.”
In Cannon, the Plaintiff argued that he was not provided a full and fair review since Aetna failed to provide him the complete claim file upon request. If he had received the complete claim file, he would have been able to determine that Aetna failed to provide all of the records requested by its peer review physician needed in order to make a fair decision on his claim. If he had known these records were never provided, he would have sent them to Aetna to provide to the reviewing physician. However, by the time the Plaintiff had discovered this information was never sent, the final decision was already rendered by Aetna and his administrative record was closed. The court agreed that the failure to provide the entire claim file was clearly prejudicial to the Plaintiffs claim. The court remanded the claim back to Aetna for further review.
When your claim is denied by your insurance company, it is pertinent to request your complete claim file in order to determine exactly what your insurance company did during the review process of your claim. As seen above, the failure to review the claim file prior to the close of your claim can cost you your benefits.