• An Amazon Long Term Disability Insurance Claim Against Aetna

Indiana District Court criticizes Aetna for denying benefits to Amazon Employee

A common question we receive is, How can an insurance company rely on their own doctors over the opinions of treating physicians? Or, How can an insurance company rely on doctors who merely review a paper file and never see the claimant in person?

Unfortunately, insurance companies are allowed to do this as long as they have a good reason for doing so. If the insurance company’s doctor’s opinion is different from your treating physician they have to provide a good reason why. To seem reasonable, the insurance company will often require its hired doctor to perform a peer review by reaching out to the treating physician and discussing the claimant’s condition.

That is what happened in a recent case out of Indiana involving Aetna Life Insurance Company. Upon review by an Indiana Federal District Court, several errors were found when a judge reviewed Aetna’s decision. The case involved an Amazon Employee who claimed she was unable to work due to severe urinary incontinence.

Despite undergoing surgery and multiple Botox injections she suffered from uncontrollable urinary incontinence and her doctor certified her disability. Despite the evidence submitted, a nurse reviewer deemed the evidence insufficient and the claim was denied. On appeal, Aetna obtained a physician review and upheld its denial based on an alleged conversation the reviewing doctor had with one of the treating doctors.

Following the decision, the claimant wrote to Aetna, challenging its use of the conversation with a doctor who was not the one certifying disability, which the court deemed a part of the record.

In court, it was argued that Aetna’s doctor had falsely stated that further surgery was not recommended, that Aetna failed to consider all of the medical evidence and that the opinions of the doctor who certified her disability were rejected without any discussion.

The evidence showed plaintiff’s condition was not improving and symptoms were reported as “severe and persistent” yet Aetna’s reviewing doctor’s opinions were based on his faulty assumption that invasive treatment was not being considered.

On review, the court was troubled with Aetna’s disregard of plaintiff’s primary physician and criticized Aetna for failing to provide a reasonable explanation for disregarding the doctor’s opinions. The court also pointed out Aetna’s mischaracterization of doctor’s notes describing surgeries as “uncomplicated.” The court observed that “such findings indicated only that the surgery went as expected—not, as Aetna seemed to suggest, that they remedied the claimant’s conditions. The same is true with the “normal” observations made in some medical opinions.”

Finding Aetna’s file review clearly biased, the court remanded the case back to Aetna. Despite its grossly inadequate assessment of a severe claim Aetna was not ordered to reinstate the claim. Given the level of procedural and substantive violations the court should have awarded benefits to this claimant outright without giving Aetna the opportunity to deny the claim again.

This case is a perfect example of what a “win” can represent for claimants with even severe conditions when dealing with ERISA. Although the court found Aetna’s decision was wrong and unreasonable it did not award benefits to the claimant but instead gave Aetna another opportunity to perform further mischief.

This case was not handled by our office, but it may provide claimants guidance in their pursuit of disability benefits. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.

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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.

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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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Simply The Best. I chose Dell & Schaefer after watching several videos that Greg had made and I also checked his reviews. I contacted him through his website and within 1 hour Greg called me on a Sunday afternoon. We discussed my medical issues and how they were rapidly damaging my abilities to continue my dental practice of 32 years. He told me that he would handle my case himself. I asked for names of dentists that he had represented. I spoke to 3 and they all said hire Greg ASAP. I had 3 specialists who recommended that I stop practicing but I had a tough time dealing with losing my practice of 32 years. I was dealing with depression and anxieties due to my reduction in hours along with knowing that my disability insurance company had a bad reputation of denying legitimate claims. Greg had a way of calming me down and he told me he had dealt with my company hundreds of times. He was not at all intimidated. He said that he was going to help me and was confident that we would win. Greg guided me through the entire process and it was completed in the time frame he said it would be. He and Vanessa returned all my calls and emails rapidly.

I would think of questions on weekends or late at night and he would always return my emails and calls. Once everything was into the insurance company they had an inexperienced claim consultant on my case that was challenging my disabling conditions. Greg fired off a letter giving them 5 days to make a decision. They moved my case up the ladder to a “lead” consultant and within 2 days we had the approval letter. He was also able to collect a period of partial disability, my business overhead expense policy, get me deemed totally disabled get my three insurance premiums refunded to me. We also received all past due benefits for the maximum monthly payment for the past 8 months since I stopped working. Greg continues to handle my claim and thankfully he will always be on my claim until my policy expires.

My family will be thankful to Greg, his assistant Vanessa and their entire team forever.

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