Nevada disability lawyer and COX Enterprises Inc’s customer service rep sue AETNA Life Insurance Company for denial of disability benefits

A former Customer Service Representative (CSR) for COX Enterprises Inc. (COX) recently filed a lawsuit through a Nevada disability attorney against the AETNA Life Insurance Company (AETNA Life) at the District Court for the District Court of Nevada. In Sandra Rada v Cox Enterprises Inc as Plan Administrator & AETNA Life Insurance Company as Claims Administrator, the plaintiff Sandra Rada alleged that AETNA Life had not provided the plaintiff with a full and fair review of her claim for long term disability (LTD) benefits and thus seek the Court to review Aetna Life’s decision under a de novo standard.

Aetna Disability Claim Denial History

The plaintiff, beginning January 1st 2005, was employed as a CSR with COX. Her duties as a CSR among other things included handling incoming customer calls; introducing and selling new or additional products or services; reviewing customer inquiries/problems and determining an appropriate solution or response; negotiating customer claims; initiating billing adjustments; arranging product substitution or returns; assessing customer needs; processing incoming orders; and providing clerical/administrative support to the customer service functions. As an employee of COX, the plaintiff participated in a Welfare Benefits Plan (which included a LTD flex plan) that was sponsored by COX. The Welfare Benefits plan also designated AETNA Life as the Claims Administrator.

On March 13th 2008, the plaintiff was involved in a motor vehicle accident. As a result of the accident, she sustained head trauma, scalp laceration which required 30 stitches, multiple contusions and injuries to the back and neck. Since the March 13th accident, the plaintiff alleged that she suffered from post-concussive syndrome which included anxiety, depression, headaches, memory loss, difficulty concentrating, word-finding problems, sleep disturbance, confusion and fatigue. Prior to the March 13th accident, the plaintiff also had a history of chronic back and neck pain due to two previous motor vehicle accidents. She was already having medical treatment for these past injuries when the March 13th accident aggravated her condition.

Definition of ‘Total Disability’ under the Aetna Disability Plan

Under the Welfare Benefits plan that the plaintiff participated in, the plan defined total disability as:

In the first 24 months of a period of total disability: You are not able, solely because of injury or disease, to work at your own occupation.

After the first 24 months of a period of total disability: You are not able, solely because of injury or disease, to work at any reasonable occupation. (This is any gainful activity for which you are, or may reasonably become, fitted by education, training or experience. It does not include work under an approved rehabilitation program.)

Due to her medical conditions, the plaintiff applied for long term disability benefits under the above mentioned plan in August 2008. The claim was approved and AETNA Life paid LTD benefits to the plaintiff from September 14th 2008 through April 9th 2010. Concurrently, the plaintiff also applied for social security disability benefits which was approved and awarded to the plaintiff on January 22nd 2010 by the Social Security Administration (SSA). In its determination, the SSA deemed the plaintiff as being disabled from December 6th 2009. Aetna gladly deducted the amount of the social security disability award from the plaintiff’s check each month. Despite the findings of SSA, Aetna later disagreed with the SSA findings of total disability.

Conversion of Disability Definition from ‘Own Occupation’ to ‘Any Reasonable Occupation’

On February 25th 2010, the plaintiff’s case was referred by AETNA Life for a peer review by an occupational medicine specialist. The specialist hired by Aetna opined that the medical documentations provided by the plaintiff did not support a functional disability from any occupation. The review was forward to the plaintiff’s attending physician by AETNA Life for comment and requested an explanation or documentation if the attending physician did not agree with the opinion of the occupational medicine specialist. ATENA life also requested that the attending physician responded within 15 days which unfortunately the attending physician did not do so until April 22nd 2010.

An Occupational Analysis prepared by AETNA Life on April 8, 2010 concluded that the plaintiff would be able to engage in several different occupations based on her training and education and on the findings of its peer reviewer that she could work a sedentary job. Thus, AETNA informed the plaintiff on April 14th 2010 that it was terminating the plaintiff’s LTD benefits effectively from April 9th 2010. The ground for the termination of the plaintiff’s LTD benefits was that she was not disabled from any reasonable occupation due to the lack of response from her attending physician to the peer review and an absence of “objective medical evidence of restrictions precluding her from working a full-time sedentary job.”

The Appeal of AETNA Disability Claim Denial

The plaintiff in view of AETNA Life’s decision to terminate her LTD benefits submitted an appeal to the decision on January 10th 2011. Further medical documentations and clarifications were provided by the plaintiff to AETNA Life to support her appeal. In February 21st 2011, AETNA Life “partially overturned” its April 14th 2010 decision. It extended benefits to the plaintiff from April 9th 2010 to November 30th 2010. It refused to pay LTD benefits beyond November 30th 2010 because

the records presented for review do not provide any abnormal examination findings, imaging studies, or behavioral observations, dated after 11/30/10, to document any specific impairment that would prevent [her] from performing the work of any occupation.

According to AETNA Life, this decision was based on three physician reviews and peer-to-peer conversations conducted.

The Claim For Relief

As a result of ATENA Life refusal to consider its denial of LTD benefits to the plaintiff beyond November 30th 2010, the plaintiff was forced to file a lawsuit against AETNA Life for the wrongful denial of benefits under ERISA. In the lawsuit, the plaintiff alleged that AETNA Life failed to consider the medical opinion of her attending physicians and the determination of her disability status by the SSA and arbitrarily terminated her LTD benefits. As such, the plaintiff is seeking the following relief from the court:

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

Leave a comment or ask us a question

FAQ

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.

Reviews   *****

Jodi C.

Despite the fact that I work at a law firm who handles different types of cases, I had an incredibly difficult time finding a firm that would take my disability case against Northwestern Mutual. I was so pleased when Dell & Schaefer agreed to represent me. This has been an extremely stressful and difficult time trying to receive the benefits which I was owed, while also dealing with serious medical conditions and physical limitations. My main diagnosis is fibromyalgia syndrome, which has completely changed every aspect of my life. I could not ever have imagined that I would be so lucky as to find such a firm as Dell & Schaefer and an attorney like Alex Palamara.

From the very beginning, he and his staff were so very helpful, knowledgeable, kind, understanding and committed to me and my case. I have now learned that disability cases against private insurance carriers are very different than a social security disability claim. I had to completely rely on Alex Palamara’s professional knowledge and experience with my case. Alex, his firm and his staff went above and beyond to assist me in every way. They were very clear in explaining these types of cases, and my case in particular. Working in the legal field as a secretary, I know how frustrating it can be for clients when they don’t have regular communication with their attorney, or have questions that need to be answered.

Alex always immediately responded to me and answered every question I had. He also always made sure that I was given any update or new information regarding my case. I could not be happier with the representation I received from Alex Palamara and everyone at Dell & Schaefer. From the very beginning, through and including mediation, Alex was completely prepared regarding every aspect of my case, medical condition, limitations, extensive documentation, and my situation in every way. I truly do not know what I would have done had I not found Alex Palamara and Dell & Schaefer to represent me in this matter. I normally hesitate to recommend a professional to others, but not in this case. I would very highly recommend Dell & Schaefer, and especially Alex Palamara, to anyone with a disability claim in need of representation. Despite the awful personal situation that brought me to Alex and his firm, he and his staff made it as stress-free as possible, and brought my case to a close in a professional and respectful manner and timeframe.

Read 424 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us