Federal Court Orders Aetna to Pay Long Term Disability Benefits to Their Own Employee

A Georgia Federal Court recently concluded that Aetna abused its discretion in denying long term disability benefits to an Aetna employee who suffered from chronic pain due to Lupus, Fibromyalgia, Asthma, Hypocalcemia and Mild Degenerative Joint Changes. Aetna unreasonably denied benefits by relying on flawed peer review reports of the plaintiff’s medical records. The court found the reports “ignore and mischaracterize the evidence” and “come to findings contradicted by the evidence.” The court held that the plaintiff was entitled to a judgment “awarding her 18 months of Long-Term Disability benefits…”

Although this recent Georgia Federal ERISA long term disability case was not handled by our disability insurance lawyers, it is a victory for claimants who suffer from chronic pain due to multiple medical diagnoses. We felt that disability insurance claimants could learn a lot from the findings of this disability law suit.

The Georgia Federal Court Identified Specific Errors of Peer Reviewers Reports Which Aetna Unreasonably Relied on in Denying the Long Term Disability Claim

Aetna denied plaintiff, its own employee, LTD benefits on the grounds that the independent medical reviewers did not find support for her disability claim in her medical records. The court found that Aetna erred when it “refused to credit reliable evidence from the plaintiff’s medical records and relied on flawed peer reviews.” The court found several specific problems with the peer reviews.

1) One reviewer concluded that the plaintiff’s medical records indicated that her fatigue did not affect her ability to “drive, balance, stand or walk.” This completely ignored the medical evidence that the plaintiff came to one medical appointment in a wheel chair and another one using a cane. Also, two separate treating physicians had concluded that her chronic fatigue and pain made it difficult for her to move. One treating physician concluded that her movement was limited due to her fatigue which prevented her from engaging in day-to-day activities.

2) One reviewing physician erroneously concluded the plaintiff just was not motivated to work. This ignored statements of a treating physician and the plaintiff herself that she wanted to return to work. This reviewing physician also concluded that chronic pain cannot be disabling. This is in direct conflict with an Eleventh Circuit opinion from 2009 that held it is erroneous for plan administrators to deny benefits for chronic pain syndrome and fibromyalgia when the medical records support disability due to those conditions.

3) A reviewing physician stated there was no documentation that pain medication interfered with her ability to work when the records did not include the frequency or amount of opiate medications she was taking. That conclusion overlooked the clearly documented evidence that she took 20 milligrams of Oxycontin every 12 hours.

4) One reviewer discredited a Functional Capacity Exam (FCE) the plaintiff was required to undergo as part of the application process. He relied on a portion of the FCE report that stated the plaintiff gave ‘inconsistent effort throughout the evaluation.” The comment ignored the part of the report that said the inconsistent effort only related to grip strength and hand coordination. It also overlooked the rest of the report that indicated she had used maximal effort in all other aspects of the test.

The court concluded that although plan administrators may rely on independent physician reviews over opinions of treating physicians, “it is not reasonable for plan administrators to rely on opinions like those [of the two reviewing doctors] that ignore and mischaracterize evidence.” Since the medical evidence supported the plaintiff’s claim that she could not work at her sedentary job, the Georgia federal court ordered: “The Plaintiff is entitled to a judgment awarding her 18 months of Long-Term Disability benefits and the matter is remanded to Aetna to determine whether she is disabled from any occupation.”

If you have questions regarding your claim for disability benefits, or if your disability claim has been denied, feel free to call Disability Attorneys Dell & Schaefer for a free consultation.

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