Executive Director with Meniere's Disease Denied Disability Benefits By Hartford

Our client, came to us when he was unjustly denied his claim for LTD benefits by Aetna, now Hartford, asserting that his medical records did not demonstrate “a consistent inability to perform [his] sedentary occupation”.  Aetna abused its discretion in reaching this determination as its decision was not only wrong but arbitrary and capricious and was not based on a full nor fair review of his claim. Our client is a former Executive-Internal Audits for The Depository Trust & Clearing Corporation who has long suffered from the debilitating effects of Meniere’s disease. Meniere’s is a chronic, incurable disorder of the inner ear characterized by unpredictable episodes of severe vertigo and dizziness along with symptoms to include but not limited to ear pressure and pain, hearing loss, balance instability, and cognitive dysfunction. He developed Meniere’s in the mid 1990’s and has undergone surgical intervention to include anendolymphatic shunt in 1995 and a vestibular neurectomy in 1996 without any significant improvement to his condition. In fact, the neurectomy resulted in loss of functional hearing in our client’s right ear as well as the onset of constant and severe tinnitus. His Meniere’s also progressed bilaterally with the healthier left ear becoming diseased in 2008.

Despite the severity of his condition, our client was not yet ready to give up on his rewarding career, struggled to continue working while enduring great physical and cognitive difficulties. Unfortunately, his condition continued to deteriorate and on March 28, 2019, he was ultimately forced to cease working and apply for Long Term Disability Benefits under his policy with Aetna. Aetna, clearly seeking to avoid liability under its LTD policy, neglected to provide him with a full and fair review, and unjustly denied his claim for disability on the false assertion that he did not meet the LTD policy’s definition of disability. Upon review of his claim file, it was evident that Aetna’s review, assessment, and conclusion were not only wrong but flawed for several reasons.

In its decision letter dated October 15, 2019. Aetna asserted that our clients “medical records do not show a consistent inability to perform [his] sedentary occupation throughout the 180 day Elimination period which is from [his] date of disability 3/28/19 through LTD benefit date of 9/24/19. Therefore, [his] Long Term Disability claim is denied”. This assertion, however, was not only wrong but inconsistent with Aetna’s own determination on his Short Term Disability (STD) claim. Utilizing the very same medical records as well as essentially the same definition of disability as the LTD policy, Aetna had previously found our client to be disabled under its STD plan and approved his STD claim from March 28, 2019 through the STD benefit maximum date of October 2, 2019. As this period of time overlaps the LTD elimination period, it was illogical for Aetna to later determine that his medical records did not show an inability to perform his occupation through the LTD elimination period. Not only was this contradictory but arbitrary and capricious.

In an eagerness to deny benefits, Aetna equated his occupational duties to that of an Auditor (DOT #160.167-054). However, his high functioning and demanding role as Executive Director- Internal Audits far exceeded that of just an auditor. Our client’s occupation as Executive Director, on the other hand, involved not just auditing but also the management and oversight of a team of professionals, relationship building, meeting deliverables, and presenting to executive and board members amongst many other taxing functions. Given the severity and progression of his Meniere’s disease as substantiated by his medical history and the medical records, he would certainly be unable to effectively perform the aforementioned functions with reasonable continuity and reliability. This would have been evident to Aetna if they had performed their due diligence in appropriately assessing and considering the demands of his occupation. To dispute Aetna’s erroneous conclusions, we retained a Vocational Specialist to perform an Independent Vocational Assessment which not only confirmed that her would not be unable to perform the material duties of his occupation on a sustained basis but also correctly determined his occupation to be consistent with that of a Financial Services Vice President (DOT#186.117-078) not an Auditor as incorrectly asserted by Aetna.

In an Attending Physician Statement form dated April 12, 2019, his neurotology physician specialist, who has been responsible for his treatment since 1995, confirmed his inability to effectively perform the material duties of his occupation as Executive Director on a sustained basis due to the progression of his Meniere’s disease and secondary diagnoses of imbalance and hearing loss. Specifically, his doctor documented that his severe impairments currently rendered him incapable of performing the critical occupational functions of managing a workload, performing leadership functions, conducting presentations, performing technical reading and data analysis, and engaging in long term computer work. His doctor’s corresponding office notes substantiated his opinion demonstrating a progressive severity of impairment that would in fact preclude work in his high functioning and cognitive demanding role. In a telephonic contact documentation dated September 27, 2019, his doctor noted advising Aetna’s physician consultant, Dr. David Foyt, of our client’s disability and even indicating that he was “quite surprised and impressed that he has worked as long as he has with his current symptom complex”.  Unfortunately, in an effort to facilitate his employer’s, Aetna, predetermined decision to deny benefits, misrepresented conversation with treating doctors and the consultant report dated October 7, 2019 minimized the expressed severity of his disability.

It is clear from the review of Aetna’s claim file and claim denial letter that Aetna’s review, opinions, and ultimate decision to deny his benefits were not only FLAWED, but arbitrary and capricious and demonstrated an abuse of any purported discretion that it may have under the LTD plan. The medical evidence from our client’s treating physicians and even the opinion of Aetna’s own physician consultant substantiates a severity of impairment related to diagnosis of Meniere’s disease that would prevent him from performing with reasonable continuity and reliability the material and substantial duties of his high functioning and cognitive demanding occupation as Executive Director-Internal Audits. In an Attending Physician Statement (APS) dated March 5, 2020, his treating doctor confirmed his ongoing, “severe – extreme”, symptomatology to include vertigo, dizziness, imbalance, cognitive dysfunction, short term memory deficits, mental confusion, and fatigue. He further noted that he would be unreliable in the work place with frequent absences and unscheduled breaks due to exacerbations of symptoms.

After reviewing our in depth appeal, Aetna/Hartford overturned their decision to deny his LTD benefits, admitting that our client was indeed disabled and paid him his back benefits he was owed since the date his claim was filed. We are currently managing his claim to ensure that he stays on claim as long as he remains disabled under the terms of the policy.