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Dell & Schaefer ERISA Administrative Appeal Successful: Claimant suffering from Sleep Disorders, Depression and Fibromyalgia Now Receiving Long Term Disability Benefits

Attorney Alex PalamaraAuthor: Attorney Alex Palamara

Attorney Alexander Palamara of Dell & Schaefer is happy to report of another client’s approval for Long Term Disability (LTD) benefits by Aetna. Our client previously worked as a Nurse for the Lee Memorial Health System in Florida since 2001. Unfortunately for our client, she began to suffer from the following medical conditions: Narcolepsy with Cataplexy; Severe Obstructive Sleep Apnea; Insomnia; Hypersomnia; Sleep Paralysis; Chronic Fatigue; Dizziness, Major Depression, Recurrent Episode, Severe; Post Traumatic Stress Disorder; Bipolar Disorder; Morbid Obesity, in partial remission; Peri-Menopause; and Fibromyalgia. These conditions left her unable to perform the material duties of her own occupation.

Fortunately for our client, working for Lee Memorial Health System provided her with Long Term Disability Insurance Coverage for such a situation. Our client was forced to leave work in early April 2014 and filed a claim for LTD benefits by herself shortly thereafter.

Claim Initially Denied

Unfortunately for our client, Aetna Life Insurance Company, the Long Term Disability Claim Administrator and Payer of Benefits, denied her claim by way of a denial letter dated July 18, 2014. In its denial letter, Aetna ultimately concluded that our client was not disabled as defined by the policy as of July 17, 2014, the date benefits should of begun. Aetna stated that the clinical information it had on file was “insufficient to support the presence of a functional impairment from a physical or mental perspective… and therefore we find that you do not meet the definition of disability…”. In support of its contention, Aetna relied upon a clinical review by one of its employees and a “medical peer review.” Within a few days of receiving the denial letter from Aetna, the claimant found us and quickly became a client of Dell & Schaefer.

Administrative Appeal filed by Dell & Schaefer

After reviewing the Administrative Record provided by Aetna, as well as the medical records of the client, it was apparent to us that Aetna’s decision was blatantly incorrect, as well as arbitrary & capricious. Furthermore, the “reviews” that Aetna relied upon were not found in the complete administrative record provided to us. Needless to say, those reviews were misguided at best.

Our client’s medical records and the support of her treating physicians were overwhelming. Furthermore, prior to the time that we filed an administrative appeal, our client was approved for Social Security Disability Benefits. Armed with the above, an administrative appeal was timely filed which challenged Aetna’s denial of her claim.

Within 5 weeks of the filing of the administrative appeal, Aetna sent a letter stating that our client’s claim had been re-opened for benefit payments. Thus Aetna has agreed with our contention that our client is unable to perform the material duties of her own occupation. The back benefits owed to her will be paid shortly and our client will be receiving a monthly benefit for the time being and hopefully the long future.

Though our client is back on claim, she knows the fight does not end. After 24 months of benefits, it typically becomes more difficult to stay approved under most LTD Group ERISA policies. This is due to the change in definition of disability. At that point, the client will have to prove that she is “unable to work at any reasonable occupation.” Though the change in definition of disability is not close to occurring, the attorneys at Dell & Schaefer will continue to fight to ensure that Aetna does not deny her claim now or in the future.

If you have been denied Long Term Disability Benefits by Aetna or any other insurance provider, please do not hesitate to contact the Attorneys at Dell & Schafer for a free consultation.



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