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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.

Comments (4)

  • Sal: It sounds as though you have a number of complex medical and timing issues going on with you claim. I suggest you contact our office and speak with one of the attorneys to address the specific questions you have regarding your situation.

    Jay Symonds Feb 8, 2020  #4

  • I have a disability insurance with NY life who transferred my policy first to Paul Revere who then transferred it to Unum. I have been trying to get benefits for disability since 2003/2004 with constant denials. I now am running out of time. I have moved from NY to Florida and the lawyer who filed my claim with Unum has moved to Texas.

    I was told I need a lawyer licensed to practive in NY, since NY Life is stationed in N.Y. In 2017 I was diagnosed with stage 4 colon cancer and have been fighting my cancer in addition of my work related disability since. I was approved for permanent disability by the government but Unum still refuse my claim. Please help. If you are not in a position to help, could you please reffer my claim to someone you know can help? Its a few million $ case, so please help.

    Sal M. Feb 8, 2020  #3

  • Anibal,

    Please feel free to contact our office to discuss your claim and how we may be able to assist you.

    Stephen Jessup Nov 7, 2013  #2

  • I been denied from Aetna even know they have all the documentation from the doctor. Now that I get social security disability Aetna reopened the case, but I would like a professional attorney to get my case.

    Anibal Vazquez Nov 6, 2013  #1

Leave a comment or ask us a question

Questions About Hiring Us

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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