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Court Rules Aetna Erred in Denying Long term Disability Benefits

In Charles v. UPS National Long Term Disability Plan et al., the plaintiff, Marvin Charles, was being treated for a reoccurrence of a seizure disorder, a condition that had been dormant for about 30 years. In 2008, he had a grand mal seizure and consulted with his physician who prescribed Lacmital, a medication used for the control of seizures. He was granted 24 months of short term disability when Aetna agreed he was unable to perform the duties of his own occupation.

Aetna Denied Long Term Disability Benefits When There was no Objective Proof Plaintiff Suffered From Fatigue

After 24 months, plaintiff applied for long term disability. At this time, the definition of disability changed and now Charles was required to prove he was disabled from performing the duties of any reasonable occupation. His treating physician reported that Charles was disabled from performing the duties of any occupation due to the fatigue he suffered from as a side effect of Lacmital. The Lacmital could not be discontinued because it kept his seizure disorder under control.

Aetna denied Charles long term disability benefits on the grounds that there was no objective proof Charles suffered from fatigue. In its decision finding Aetna abused its discretion in denying Charles long term disability benefits, the Pennsylvania District Court relied on Third Circuit precedent and held, “Aetna’s expectation that the plaintiff should undergo some additional ‘clinical’ test to prove that he is, in fact, experiencing fatigue from his medication is arbitrary and capricious.”

Court Ruled Against Aetna Holding That it Abused its Discretion in Requiring Objective Proof of a Medical Condition When no Objective Proof Exists

Plaintiff’s treating primary care physician repeatedly reported that Charles suffered from fatigue, as a side effect from Lacmital, to a degree that he could not be employed full time at any reasonable occupation. Aetna seemed to ignore those reports and relied instead on its independent reviewers of plaintiff’s medical records who claimed there was no clinical or objective evidence to support the restrictions placed on the plaintiff’s ability to work.

The federal district court noted it was “not clear what type of clinical evidence Aetna thought was missing” and went on to recount the evidence supporting the plaintiff’s complaints of fatigue:

The court ordered Aetna to pay long term disability benefits, finding that for Aetna to expect more documentation “under these circumstances is an abuse of discretion.” The court relied on a 1997 case that held it was arbitrary and capricious for an insurer to require clinical evidence for “a condition with no ‘dip-stick’ lab test.”

This case was not handled by our office, but it may provide claimants guidance in their pursuit of long term disability when they suffer from a condition, such as fatigue, for which there is no “dip-stick” lab test that exists that can provide objective evidence of the condition. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.

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Do you help Aetna claimants nationwide?

We represent Aetna clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Aetna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Aetna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Aetna.

How do you help Aetna claimants?

Our lawyers help individuals that have either purchased a Aetna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Aetna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

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