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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.

There is one comment so far

  • I am the wife and demeatic partner of a husband that was awarded LTD benifits from 2012 til 2028 he was collecting them and he died . I was interested home as his wife and on ssi taking care of him. Is there any way I can get his balance of his clIm to his estate im the beneficiary of the estate.

    Lisa May 2, 2022  #1

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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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