Through a disability insurance lawyer, a lawsuit was filed at the District Court for the District of Utah by a disabled Network Design Engineer formerly working at Unisys. In the lawsuit, it was claimed that the Aetna Life Insurance Company’s (Aetna Life) failure and refusal to pay the plaintiff long term disability (LTD) benefits under an employee welfare benefit plan underwritten and insured by Aetna Life constituted a breach of the terms and provisions of the Plan and of the Employee Retirement Income Security Act of 1974 (ERISA).
The Alleged Facts of the Case: Disability Attorney filed legal action under ERISA
In Michael Capener Vs. Aetna Life Insurance Company And Unisys Flexible Benefits Program, Long Term Disability Plan, the plaintiff Michael Capener was working at Unisys as a Network Design Engineer. While employed at Unisys, the plaintiff participated in an employee welfare benefit plan underwritten and insured by Aetna Life. Under the terms of the plan, the insured was to receive Long term disability benefits if the insured became disabled and:
Is unable to work your normal schedule due to a disability that lasts longer than 26 weeks.
Long term disability is defined as:
during the first two-year period you are considered disabled if all of the following apply:
- You are unable to work your normal work schedule due to the disability.
- You are being treated for your illness, injury or pregnancy by a licensed physician.
- It can be verified by Aetna (the LTD Claims Administrator – see page 486) that you are unable, due to your disability, to perform the essential functions of your regular occupation at any job site within the Company. Essential functions include the ability to work your normal work schedule. In order to satisfy this condition your physician(s) must provide Aetna with objective, documented and clinically measured or observed impairments of a severity and intensity that limit functioning at the level required to perform the essential functions of your job.
The Claims for Disability Benefits
On November 2008, the plaintiff was diagnosed as suffering from chronic fatigue syndrome (CFS) by his primary care physician. The symptoms of his medical conditions included difficulty in sitting and standing, difficulty in solving complex problems, excessive fatigue, memory problems, muscle pain, orthostatic intolerance (a sudden fall in blood pressure), post exertional malaise and unrefreshing sleep. As his symptoms worsened, the plaintiff became unable to perform the duties of his job.
The plaintiff was recommended by his primary care physician to work less than 8 hours a day. The plaintiff continued working until November 30th 2008. On December 1st 2008, he applied for short term disability (STD) benefits. According to the lawsuit, the plaintiff attempted to work on a part-time basis in January 2009 but nevertheless had to quit due to the symptoms of CFS.
On April 2009, the plaintiff filed a claim for LTD benefits. It was stated in the lawsuit that the plaintiff was being treated by a CFS expert and consultant to the National Institutes of Health who provided Aetna Life with medical reports since March 2009. Accordingly, the medical report had continually affirmed the disabling status of the plaintiff caused by CFS and had rendered the plaintiff unable to work.
Denial Of LTD Benefits Claim by Aetna
Nevertheless, on June 1st 2009, the plaintiff was informed by Aetna Life that his Aetna disability application was denied as he didn’t meet the requirement of the 26 weeks elimination period. A complaint was filed by the plaintiff on June 25th 2009 against Aetna Life and the Unisys Flexible Benefits Program for the reinstatement of STD and LTD benefits. It was stated in the lawsuit that the matter of the STD benefits was later fully settled and compromised. In the “Stipulated Motions for Dismissal with Prejudice of STD Claims and Dismissal without Prejudice of LTD Claims,” filed on November 11th 2010, it was stated that:
In accordance with the provisions of their Confidential Settlement Agreement the parties hereby stipulate and agree that in the event Plaintiff, after dismissal of his LTD claim without prejudice, and after Aetna’s further review of his LTD claim, files further litigation with respect to his LTD claim Aetna will not assert that Plaintiff is barred from asserting his LTD claim because he did not receive the full 26 weeks of STD benefits and Aetna will not assert that any Unisys Defendant should be joined as a party of is obligated to indemnify Aetna with respect to benefit payments under any LTD claim asserted by Plaintiff. The parties stipulate and agree, therefore, that the civil action may be dismissed with prejudice as to Defendant Unisys Flexible Benefits Program (which includes the Unisys STD plan the Unisys LTD plan) all Plaintiff’s claims against those entities having been fully settled and compromised.
On December 7th 2010, among other things, Aetna Life updated the plaintiff on “the status of our evaluation of Mr. Capener’s entitlement to Long Term Disability (LTD) benefits” and also to ask for “current medical information from all treating providers”. The plaintiff responded to Aetna Life by sending via Federal Express an LTD benefits ERISA appeal letter dated January 11th 2011, updated medical records and other documents that reconfirmed the plaintiff’s total disability status due to CFS. The plaintiff also sent a notification from the Social Security Administration’s (SSA) which stated that the plaintiff had been approved for social security disability benefits by the SSA.
An Aetna Life representative signed and confirmed receipt of the plaintiff’s package on January 12th 2010. The plaintiff alleged in the lawsuit that to date, Aetna Life had not responded to the plaintiff’s appeal letter dated January 11th 2010.
The plaintiff argued that Aetna Life in handling his claim for LTD benefits had acted:
- Contrary to the terms and conditions set forth in the Plan.
- Contrary to the reports and assessments of the plaintiff’s attending physicians.
- Well below the “higher-than-marketplace quality standards” imposed by ERISA according to Metropolitan Life Ins. Co. v. Glenn (2008).
Alleged Legal Basis for The Lawsuit by the Plaintiff against Aetna Life
The plaintiff argued that he has consistently met the Plan’s definitions of disability since its onset. The plaintiff contended that Aetna Life had never reviewed the plaintiff’s claim with a physician qualified to diagnose or treat CFS. As such, it was alleged by the plaintiff that Aetna Life had not given him a full and fair review of his denied claims. In addition, the plaintiff alleged that Aetna Life failure to respond to the plaintiff’s appeal for LTD benefits in a timely manner is a failure of the Plan to establish or follow ERISA’s claims procedure requirements. Hence, the plaintiff argued that he is deemed to have exhausted the administrative remedies available under the Plan and is entitled to bring this lawsuit.
Relief Sought By The Plaintiff
The plaintiff is asking the Court for the following relief:
- For an Order requiring Aetna Life to pay LTD benefits to the plaintiff.
- An award of pre- and post-judgment interest.
- An award of attorney fees
- Any further relief as the Court deems equitable.