Court Rules Aetna Erred in Denying Long term Disability Benefits
Author: Attorney Gregory Dell
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 Food and Drug Administration has listed side effects of the medication which include tiredness, insomnia, and sleepiness as well as others that cause a person to be fatigued.
- The plaintiff’s self-reporting of fatigue.
- Plaintiff’s primary care physician and neurologist both found that his fatigue was due to a side effect of the medication.
- The two treating physicians were monitoring his treatment and both believed Charles needed to continue taking Lacmital despite his fatigue because it kept his seizures under control.
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.