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:
- Review the termination of benefits under a de novo standard of review
- Declare that she is entitled to past LTD benefits from December 1, 2010 through the present
- Reinstatement of her LTD benefits
- An award of pre-judgment interest through the date of payment
- Payment of attorney’s fees and costs associated with attempting to secure the benefits owed to her