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

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:

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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Michael F.

Having had several lung surgeries including a wedge resection, lobe removal and pleurodesis as well as MAC lung disease, I was diagnosed with stage vi (end stage) COPD in October 2012. With my lung function at 23% it was becoming very difficult to manage my daily life let alone continue working in my management role at a large healthcare company. After meeting with my primary physician and my pulmonologist, it was agreed that I should stop working and submit a claim for disability. I was 52 at the time. My short term disability plan with Mutual of Omaha paid my claim for 3 months at which time it was converted to my long term disability plan with no issues. I continued to collect my LTD benefit from February 2013 until November 20th 2014 when I received a letter saying I could return to my previous position and there was nothing in my medical records to indicate disability. I was shocked to say the least, as my condition is chronic and progressive and in fact my condition had continued to decline. I didn’t know what to do and knew I did not have the knowledge or experience to appeal their decision. I was very afraid as we depended on this income to pay our bills, that’s why I held the policy for many years, to protect my family. I want to add that I applied for and was approved for Social Security disability benefits shortly after diagnosis.

I immediately started to search for attorneys that handle disability claims and found literally hundreds that handled SSDI claims, but few that handled employer/private policies. I found Dell & Schaefer and filled out their quick online form and almost immediately received a reply from Gregory Dell (yes, an actual person responded!) who let me know that he asked Rachel Alters to call me. I don’t think it was more than a half hour before I received a call from her. I immediately felt a sense of relief as she explained the process and what she would be doing for me.

From that day forward, I have been met with OUTSTANDING customer service from Rachel Alters and Kathleen Bordes. Any time I reached out with questions or concerns they were very responsive and always left me feeling satisfied that I had the best in my corner. The process took many months and a lot of leg work on Rachel and Kathleen’s part. When I was finally sent a draft of the appeal, I completely understood why it takes so long. The level of detail was unbelievable. I actually feel like I better understand my disease after reading it! The appeal was filed timely and my denial was overturned very quickly. When I learned it was overturned, I have to admit I had tears in my eyes. I want to add, that even if the appeal didn’t have the positive outcome that it did, I would feel exactly the same about the exceptional job done on my case. I’m not sure I can ever truly express how grateful I am, and how blessed I feel to have found Dell & Schaefer and especially Rachel and Kathleen!

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