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Michigan Court Remands Aetna to Reconsider Disability Benefit Denial

In Coulter v. Aetna Life Insurance Company, a Michigan federal court found that Aetna committed a number of errors in its review of claimant Sharon Coulter’s medical file. In addition, it misinterpreted three separate Functional Capacity Evaluations (FCE). The Benefit Appeals Committee (BAC) for Alcoa, Coulter’s employer, relied on the information provided to it by Aetna to terminate Coulter’s long term disability benefits.

After detailed analysis of Aetna’s reasoning behind its recommendation to BAC to terminate Coulter’s benefits, the court stated, “Certain erroneous assumptions underlying Alcoa’s final decision render it arbitrary and capricious, and the Court remands to the plan administrator for reconsideration of Plaintiff’s claim for benefits.”

Summary of Basic Facts

After working for six years in the manufacturing section of Alcoa, plaintiff Sharon Coulter quit her job and was awarded short term disability benefits due to her bilateral carpal tunnel syndrome medical diagnosis. She later underwent shoulder surgery and was left with chronic pain and inability to resume her own occupation, so she was granted long term disability benefits. Even when the definition of disability changed to require her to be unable to work at “any occupation for which she was reasonably suited…,” her long-term disability benefits continued.

When Aetna took over as plan administrator of Alcoa, they reviewed Coulter’s medical file. The BAC for Alcoa relied on the information it received from Aetna and terminated her long term disability benefits. She lost her administrative appeal and so brought this ERISA lawsuit.

Court’s Analysis of the Evidence

Here, the final decision to terminate benefits was made by the BAC. Therefore, the court only analyzed the information provided by Aetna to the BAC that the BAC relied on it in making its decision. The court found that the BACs “own independent analysis of Plaintiff’’ disability claim appears to rest on the mischaracterization of the medical evidence…” Specifically, Aetna reported that Coulter could do “light to medium work” when three FCEs and medical opinions all found her capable of only performing sedentary work.

In addition, Aetna’s analysis of other jobs available to the plaintiff was flawed and, according to the court, “not supported by the record.” The jobs Aetna claimed she could do had no openings and employers who were interviewed were “‘unsure’ of whether they would be hiring in the next six months. There is no other evidence of anticipated job opportunity.”

Court’s Decision to Remand

The court struggled with whether it should award benefits or remand for reconsideration. Ultimately, it decided that remand to the plan administrator for reconsideration was the proper remedy finding that, “On this record, there is no clear entitlement to benefits and, in light of the above-mentioned defects, the Court believes that there are additional facts to develop and findings to be made as to Plaintiff’s functional ability and whether she is physically suited for the jobs selected for her.”

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

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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
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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.

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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.

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