In Darren Cohen v. Aetna Life Insurance Company [Aetna], Plaintiff was employed by STEC, Inc. as a Computer Systems Engineer where he worked on his computer for 6-8 hours a day. STEC, Inc. is a computer data storage technology company.
Plaintiff was injured while driving a Go-Kart at an employer-sponsored event. He suffered a traumatic brain injury (TBI) and spinal cord compression. He had pre-existing neck and upper extremity conditions that were exacerbated by the accident.
Plaintiff was off work for 18 months before returning for only 20 hours a week. He received long-term disability (LTD) benefits for 24 months when Aetna agreed he was unable to perform the duties of his own occupation or could only perform those duties with restrictions.
After 24 months, the definition of disability changed to requiring Plaintiff to prove he was unable to work at “any reasonable occupation” which was defined as “any gainful activity for which you are; or may reasonably become, fitted by education; training; or experience.”
Aetna then conducted surveillance on Plaintiff and performed “a paper review of his claims.” Based on the paper review, on December 6, 2011, Aetna informed Plaintiff his benefits were terminated because it believed he could work full time. Plaintiff appealed and the denial of benefits was overturned in March 2012.
In October 2012, April 2013, October 2014, Aetna reviewed Plaintiff’s medical situation and determined he was still unable to perform the duties of “any reasonable occupation.”
In July and August 2015, Aetna again ordered surveillance which occurred over several days. In September 2016, Aetna’s vocational consultant reported that it would be difficult to find a job Plaintiff could do.
In June 2017, for a third time, Aetna ordered surveillance of Plaintiff. Aetna characterized Plaintiff on the video as “very active” and that “he was performing activities that he should avoid,” so it ordered him to undergo an Independent Medical Exam (IME). A paper review of his medical records was again conducted. Based on these reports, on July 25, 2018, Aetna terminated Plaintiff’s LTD benefits. Aetna then informed Plaintiff he had the right to an administrative appeal.
The Administrative Appeal
Following the disability insurance claim denial, Plaintiff filed an administrative appeal where he submitted updated medical records, including MRI results, his own vocational analysis performed in February 2019, and physician statements. All confirmed their opinions that Plaintiff was unable to work in any reasonable occupation.
Aetna commissioned two more paper reviews of Plaintiff’s medical records. When Aetna was unhappy with one of the reports, it sent it back to the doctor and asked him to “amend” his findings. The second report supported Aetna’s view that Plaintiff could perform a full-time job with some restrictions.
On appeal, Aetna again issued its disability insurance denial. Having exhausted his administrative remedies, Plaintiff filed this ERISA lawsuit in the U.S. District Court for the Central District of California.
District Court’s Conclusion
After reviewing all the evidence presented by both Plaintiff and Defendant, and conducing de novo review, the Court found in favor of Plaintiff and stated:
The Court, reviewing all of the medical evidence on the record, finds that Plaintiff has shown by a preponderance of the evidence that he suffers from conditions that result in a loss of functionality that require restrictions that severely limit his ability to work and more likely than not require a maximum of four hours of work a day. These restrictions were approved by several of Cohen’s physicians and at least one of Aetna’s physicians. In the Ninth Circuit, ‘an employee who cannot sit for more than four hours in an eight-hour workday cannot perform ‘sedentary’ work that requires ‘sitting most of the time.’ [citation omitted.] Thus, the Court finds that these restrictions mean that Cohen would be unable to work at “any gainful activity for which experience.
Medical Evidence Supported Plaintiff’s Claim for His Disability Insurance Benefit
The Court noted that In an ERISA appeal, “it is a claimant’s burden to prove he is entitled to benefits by a preponderance of the evidence.” In finding that Plaintiff met that burden, the Court noted that even one of Aetna’s own reviewing physicians concluded that Plaintiff could not type more than 15 minutes at a time and would need to take frequent breaks throughout the workday.
The Court also commented that one of Aetna’s physicians only conducted an “8-minute physical examination” and concluded that all Plaintiff needed was an ergonomic work station with frequent breaks. The doctor did not review certain reports the Court found relevant. Another Aetna doctor simply opined that Plaintiff could work a regular work week and a third one changed his report after Aetna sent him a letter asking him to correct his report.
The Court discounted these reports of Aetna’s physicians because “Plaintiff has provided enough evidence to rebut those opinions through doctor’s visits, reports, and recommendations from 2008 to as recent as January 2019. This is enough to meet [Plaintiff’s] burden.”
Court Found Video Surveillance Did Not Rebut the Medical Evidence
In contrast to the way Aetna characterized the video surveillance, the Court reviewed it and determined it did not rebut the medical evidence in the Administrative Record that compels this Court’s findings. As noted above, the footage largely shows [Plaintiff] performing routine acts of life that do not contradict the findings of the medical professionals outline above. Indeed, even the recording of [Plaintiff’s] light jog does not persuade the Court that his medically reasonable restrictions are not supported by the record. To the extent that Aetna argues otherwise, they overstate the importance of this evidence.
The Court concluded “that Plaintiff shall be awarded past-due benefits and pre-judgment interest through the relevant period under the Policy…Plaintiff’s LTD benefits are hereby reinstated going forward.”
This case was not handled by our firm, but we believe it can be instructive to any who are struggling with a denied disability claim. No matter what stage you are at with your claim for either LTD or short-term disability benefits, contact a disability attorney at Dell & Schaefer. We will review your policy and your situation and discuss with you how we can help.