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Court Orders Aetna to Reconsider Termination of Disability Benefits Where Aetna Completely Ignored Treating Doctors Records and Recommendations

Attorney Rachel AltersAuthor: Attorney Rachel Alters

In Valentine v. Aetna Life Insurance Company, the plaintiff applied for disability benefits claiming her disability began in December 2011, when she was diagnosed with trigeminal neuralgia which caused her severe facial pain. She also claimed that her pain medications had side effects that made it impossible for her to concentrate and perform her job duties. Her claim was accompanied by medical records from her treating physician, Dr. Sirois, a specialist in cranial nerve injuries.

Her claim was denied and she filed an administrative appeal which prompted Aetna to hire a Physical Medicine and Rehabilitation specialist, Dr. Rubin, to review her medical records. In his report, issued in January 2013, Rubin stated he reviewed medical records from the date of her claim through March 30, 2012. He concluded that the records supported “functional impairment” and that “it is reasonable that these impairments will continue for another three months through 6/30/12.”

Based on that report, Aetna granted Valentine disability benefits from the date she filed her claim through June 30, 2012, at which time her long term disability benefits were terminated. Valentine then filed this ERISA lawsuit.

Federal District Court Finds Valentine Submitted Substantial Supporting Evidence That Was Not Adequately Addressed by Aetna When It Terminated Her Benefits

The District Court relied on precedent established in 2013 by the U.S. Court of Appeals for the Second Circuit which held that a plan administrator must base its decision on a full review of the entire evidentiary record and cannot ignore evidence favorable to the claimant. Comparing that case to Valentine’s, the district court commented that for Aetna to accept plaintiff’s claim for benefits through June 30, 2012, based on Dr. Rubin’s report, and deny her benefits after that “is utterly perplexing when compared to the administrative record.”

The court found Rubin’s report claiming there was no evidence to support disability after the June 30 date “entirely inconsistent with the overall administrative record.” Rubin’s report ignored records of multiple office visits and medical evaluations submitted by Valentine’s treating physician in November 2012 which verified Valentine was still suffering from the same symptoms and limitations as she had suffered from when Rubin determined she should be granted benefits. Rubin’s report also overlooked a November 29, 2012, evaluation report by a vocational expert who agreed with Dr. Sirois’s assessment that Valentine was impaired to a degree that she could not perform her job. Not only did Aetna’s consultant, Rubin, ignore these records, Aetna did not mention them at all in its termination letter.

The court remanded to Aetna concluding that Aetna’s termination of benefits “failed to address substantial evidence in the record.” It ordered Aetna to reconsider its decision based on all the evidence in the administrative record.

Although this case was not handled by our office, we thought it may provide guidance for claimant’s with similar issues. If you need assistance with your disability claim, administrative appeal or ERISA lawsuit, contact any of our lawyers for a free consultation.

You can read more about Aetna cases on this page.



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