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Court Throws Out Disability Benefit Denial Based on Aetna’s Internal Physicians’ Review

Insurance companies review the medical reasons underlying a disability benefit claim. Often, the reviewer is a doctor, nurse or economist employed on a full-time basis by the insurance company. Their job is to look for ways to deny your claim to maximize the insurance company’s profit. But keeping them honest can be difficult because their training and experience can create challenges for unsuspecting claimants or inexperienced disability benefit lawyers. That is why having an experienced Florida disability attorney is important.

Let’s examine a case against Aetna Life Insurance Company. The claimant was a computer programmer and research analyst for the University of Miami’s School of Medicine. He had long-term disability coverage under an ERISA benefit plan through the University. In August 2006, he was diagnosed with carpal tunnel syndrome and could not work. He filed for disability benefits with Aetna and his initial claim and Appeal were denied. After exhausting all options, he sued for disability benefits with Aetna, asserting the severe pain in his hands prevented him from working.

An Internal Review By Aetna Insurance Company

The claimant supplied a detailed summary of medical evidence to support his disability claim. The evidence, dating back ten years, included testimony from five separate treating physicians who agreed that the plaintiff suffered from carpal tunnel syndrome and could not perform his work as a computer programmer because of his disability. Aetna then had the claim file reviewed by two in-house physicians, who determined that no evidence of carpal tunnel syndrome existed by relying almost entirely on a diagnostic test for carpal tunnel syndrome that produced negative results. But, as the reviewing physicians conceded, the diagnostic tests were known to report false negatives. Aetna relied on the opinions of the reviewing physicians to deny the claim again because, in its view, it was not clear whether he could not work. The insurance company contended it had the right to pick between the conflicting medical testimony. The plaintiff sued, arguing Aetna wrongfully denied his disability benefits.

Aetna Relied on an Unsupported Report to Deny Disability Insurance Claim

The federal court ruled against Aetna, criticizing the insurance company for disregarding the unanimous medical opinions of five treating physicians over a ten-year period in favor of two reviewing physicians who relied on questionable diagnostic testing. The court stated that “the only conceivable reason Aetna could have for crediting the opinions of the reviewing physicians over those of the treating physicians is that the two reviewing physicians’ opinions permitted Aetna to deny benefits.” This was not a permissible reason, and the court required that Aetna pay the benefits to the claimant.



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