In the disability lawsuit of Joseph Mcdonough Vs Aetna Life Insurance Company, HM Life Insurance Company, Biogen Idec, Inc. & Biogen Idec., Inc., Group Long Term Disability Plan filed at the District Court for the District of Massachusetts, the plaintiff filed a federal lawsuit against Aetna for violations of the Employment Retirement Income Security Act (ERISA.)
Aetna Denies Long Term Disability Benefits
The plaintiff Joseph Mcdonough was a IT Technical Ops Lead/Technical Project Lead for Biogen, Idec, Inc. By virtue of his employment, the plaintiff was covered under a contract of insurance between Biogen, Aetna and HM Life Insurance Company. Both Aetna and HM Life Insurance Company were the insurer of the plan. In addition, Aetna also acted as the Plan administrator. The contract of insurance provided for long term disability benefits in the event the plaintiff was disabled within the definition of the plan.
Under the Plan, the definition of Disability is:
You will be deemed to be disabled on any day if:
- You are not able to perform the material duties of your own occupation solely because of disease or injury; and
- your work earnings are 80% or less of your adjusted pre-disability earnings.
If your own occupation requires a professional or occupational license or certification of any kind, you will not be deemed to be disabled solely because of the loss of that license or certification.
The plaintiff suffered symptoms brought about by a stroke on November 28th 2008 which included right sided numbness and weakness, loss of balance, Left Hip Bursitis and pain, Type I Diabetes, Hypertension, and Panic Attacks with PTSD.
Disability Application Filed with Aetna
As a result of the stroke, the plaintiff made a claim to Aetna for both short term and long term disability benefits for the period of time beginning on November 23rd 2008, when the plaintiff suffered from right sided weakness and numbness, was hospitalized, and diagnosed as having suffered a stroke through the present.
The plaintiff was approved for short term disability benefits for six (6) months by Aetna. Upon expiry of the short term disability benefits, Aetna approved the plaintiff’s claim for long term disability benefits on May 23rd 2009. On August 2009, Aetna began reviewing the plaintiff’s claim for continued benefits. Although the plaintiff’s attending physicians opine that the plaintiff is disabled and should remain out of work until October 9th 2010, Aetna terminated the plaintiff’s benefits on October 29th 2009 without properly assessing whether the earning capacity of the plaintiff was 80% of his pre-disability income and without providing any of the notice requirements required by ERISA to inform the plaintiff of his rights.
The plaintiff appealed to Aetna on April 21st 2010 the decision to terminate his claim for long term disability benefits and was granted an extension by Aetna until Jul 26th 2010 to submit additional information to support his ERISA appeal.
Aetna, however, sent the plaintiff a revised copy of its termination letter which contained the required ERISA’s notice requirements of the plaintiff’s rights. Although the plaintiff’s was granted additional time to submit additional information to support his appeal, Aetna started reviewing the plaintiff’s appeal on May 12th 2010 and determined that the “medical information did not support disability from own occ, 11/01/09”.
Aetna Applies Wrong Defintion Of Disability
In addition, on September 10th 2010, Aetna’s occupational medicine doctor, performed a review of some of the medical information submitted with the plaintiff’s appeal but reviewed them against the Social Security Administration criteria for determining disability. Aetna’s plan definition of disability required that the plaintiff be determined disabled in his own occupation while the Social Security Administration requires an individual to prove an inability to perform the duties of any occupation in order to receive benefits.
On November 17th 2010, after selective reviews and without any reference to the evidence submitted by the plaintiff, Aetna upheld its decision to terminate the plaintiff’s long term disability benefits.
Disability Insurance Lawyer Sues Aetna
In the lawsuit, the plaintiff alleged that Aetna:
- Failed to evaluate his claim long term disability benefits fair and fully
- Failed to comply with the provisions of ERISA
- Unreasonably, irrationally and contrary to evidence, terms of the plan and the law denied the plaintiff’s claim.
- Influenced by a financial conflict of interest in its decision making process
As a result of Aetna’s actions, the plaintiff alleged that he suffered damages and is seeking relief through the Court for:
- A declaration, adjudication and decree that the plaintiff is entitled to long term disability benefits as provided for under the plan.
- An award for the full amount of unpaid benefits under the plan together with pre-judgement interest as allowed by law.
- An order against Aetna for restitution to the plaintiff for the amount of losses sustained by the plaintiff as a result of Aetna’s action.
- An award for attorneys’ fees and cost
- An award for other relief that the court deem just and reasonable