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Court Orders Aetna to Pay Disability Benefits when Plaintiff was Found Capable of Working

Attorney Rachel AltersAuthor: Attorney Rachel Alters

In Halley v. Aetna Life Ins. Co., the plaintiff, an executive vice-president of a manufacturing company, suffered from spinal osteoarthritis and underwent numerous surgeries including a spinal fusion. He was granted three years of disability benefits when he was unable to perform the job requirements of his own occupation.

After 36 months of disability, the definition under the Aetna policy changed, allowing benefits only if the claimant was disabled from performing a “reasonable occupation”. A reasonable occupation was defined as one that would pay at least 80 percent of the earnings the claimant received prior to becoming disabled.

To see if Halley could meet the new definition, Aetna ordered an independent medical exam and a vocational assessment. Based on the conclusions of those two examiners, Aetna identified four “reasonable occupations” it said that Halley could do and therefore denied total disability benefits under the new definition. Halley filed an administrative appeal which was also denied. He then filed this ERISA lawsuit.

The Illinois Federal District Court’s Analysis of the Evidence

The court analyzed the evidence upon which Aetna based its denial of benefits and first concluded that “the fact that Plaintiff is capable of working does not end the analysis. Plaintiff may be capable of working in theory yet nonetheless be entitled to disability benefits under the Aetna LTD Policy because no ‘reasonable occupation’ is available to him.” The court focused its analysis on the conclusions of Aetna’s own independent medical evaluation (IME) and vocational assessment (VA).

Findings of Aetna’s IME: The independent medical examiner concluded that Halley could work at a sedentary job. He could start working a few hours a day and after 12 weeks, be able to work 40 hours a week, a level that would be permanent.

Aetna’s vocational skills evaluation: Based on the IME report, a vocational skills evaluation was conducted to determine what types of jobs would be available to Halley based and his education, skills, experience, wage history and work limitations due to his disability. Four jobs were identified, all executive positions rated as sedentary and with wages that were at or more than 80 percent of what Halley was earning when he became disabled.

In determining whether the four jobs identified by Aetna were reasonable, the court found:

  • All four jobs were executive positions that required up to 12 hour workdays. Aetna’s own IME had concluded Halley could only work 8 hours a day.
  • Although the jobs were rated as “sedentary,” Aetna’s independent medical examiner limited Halley’s work ability to less than sedentary, finding he could occasionally lift up to five pounds. A person in a sedentary position is expected to lift up to 10 pounds.
  • The source Aetna used for determining the “reasonabl” occupations was flawed.
  • All four jobs were executive positions with similar requirements and demands to Halley’s own occupation from which Aetna had already found Halley disabled.
  • Even if Halley could work in any of those four jobs, there was no evidence that such job opportunities existed in Halley’s geographical area.

The court concluded that Halley was capable of working 8 hours a day, 40 hours a week at a reasonable occupation. But, it ultimately concluded, “While Plaintiff—in theory—is now capable of working, the preponderance of the evidence shows that no ‘reasonable occupation’ is available to him. Accordingly, Plaintiff meets the requirements for total disability coverage under the Aetna LTD Policy.”

This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation when their insurer claims they are not disabled. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.

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