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New Jersey Federal Court Rules Against Aetna and in Favor of Systems Analyst Disabled by Degenerative Joint Disease of the Lumbar Spine

Before degenerative joint disease of the lumbar spine forced Christopher Patterson to leave his career, Mr. Patterson worked as a Systems Analyst for a consulting firm. Mr. Patterson’s employer provided long-term disability insurance through a plan administered by Aetna Life Insurance Company.

In 2001, Mr. Patterson’s back pain forced him to have lumbar surgery, after which he returned to work full-time and without restrictions. In 2006, his back pain once again returned and forced him to stop working. In early 2007, Mr. Patterson once again underwent yet another lumbar reconstruction surgery. Unfortunately, neither the first nor the second surgery proved to be the solution to Mr. Patterson’s chronic back pain and he was forced to apply for short-term and then long-term disability, which were both approved. Soon after Aetna approved his claims, he applied for social security disability, which the Social Security Administration promptly approved at the application stage and without the need for an administrative hearing.

In 2008, Aetna hired a private investigator to conduct video surveillance of Mr. Patterson. Aetna did not appear concerned with any of the surveillance since they continued paying his claim without interruption. In 2009, Aetna, again decided that it needed to conduct more video surveillance of Mr. Patterson and hired its private investigator to follow and video record Mr. Patterson’s activities over the course of several days.

The surveillance captured Mr. Patterson walking outside of his residence, gathering mail, bending at the waist, putting fluids into his truck, kneeling to check something in his vehicle, driving and twirling his cane as he walked. Four months later, Aetna again conducted more video surveillance which observed Mr. Patterson performing similar activity as the previous rounds of surveillance.

Aetna then sent Mr. Patterson for an “Independent Medical Examination” (IME) with Dr. Salvador Baylen. After reviewing the surveillance video, reviewing the medical history and examining Mr. Patterson, Dr. Baylen determined that Mr. Patterson was capable of performing sedentary work for 40 hours per week. He also opined that “after some degree of conditioning or work hardening, Mr. Patterson [would be] able to perform light duty physical work for 40 hours per week.

Following the video surveillance and IME, Aetna determined that Mr. Patterson remained totally disabled with “no ability to work” and continued approving his claim.

After 7 Years of Long-term Disability Benefits Aetna Terminates Chris Patterson’s Long-term Disability Claim

For the next five years, Aetna continued paying Mr. Patterson’s disability claim, however, again conducted yet more video surveillance in 2013, an internal medical review by a nurse consultant in 2014 and finally a vocational review in late 2014. Following the medical and vocational reviews Aetna decided it was time to terminate Mr. Patterson’s long-term disability and ceased paying benefits.

Following the submission of his mandatory administrative appeal, Aetna requested a second independent medical peer review. The orthopedic surgeon hired by Aetna to conduct the review opined that Mr. Patterson had the functional ability to sit without limitation, and walk for forty-five minutes at a time, but that he should avoid bending, twisting, or crawling, despite never physically examining Mr. Patterson. Following the medical review, Aetna informed Mr. Patterson that its decision to terminate his disability claim would be upheld on the basis that it felt he was capable of performing the material duties of his own occupation as defined in the national economy.

Federal Judge Finds Aetna’s Decision to Terminate Mr. Patterson’s Long-term Disability Claim Arbitrary and Capricious and Overturns Aetna’s Decision.

Following the exhaustion of his administrative appeals, Mr. Patterson filed a lawsuit against Aetna in the U.S. District Court for the District of New Jersey alleging that Aetna had improperly terminated his claim and sought reinstatement of his disability benefits, on-going waiver of his life insurance premiums, interest, court costs and attorney fees.

Following its review of the administrative record and the motions for summary judgment filed by Mr. Patterson and Aetna, the Court found that by not considering the actual duties performed by Mr. Patterson before he became disabled, and instead applying a broader national economy standard, which was not contained in the policy, it had acted arbitrarily and capriciously.

Furthermore, the Court was disturbed with Aetna’s inconsistent handling of Mr. Patterson’s long-term disability claim. Specifically, that:

After conducting its first and only independent medical examination conducted in April 2009, and undertaking surveillance, Aetna continued to find that plaintiff was disabled. Its own records say so: Patterson “cannot work” and the medical information “continues to support [Patterson’s] disability.” Yet the doctor who performed the IME in 2009, like the doctor who undertook the review of medical records in 2014, both found that Patterson was capable of “sedentary work.” AR 00180, 00823. So what changed in those five years…? Why was Patterson “disabled” in 2009 but not disabled in 2014 based on very similar evidence?

Following its review of the record the Court determined that Aetna’s termination of benefits was “unlawful, and as such, “benefits should be reinstated to restore the status quo.” The Court also allowed Mr. Patterson to submit an application for attorney fees pursuant to ERISA.

This case was not handled by our law firm, but it is instructive for any disability policy holder that has been denied benefits. For a Free Consultation, please contact Attorneys Dell & Schaefer.

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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.

Dell & Schaefer Client Reviews   *****

Daniel

We all make, everyone of us, life altering decisions everyday that could and often do, save or change the course of our lives. Something as simple as driving to the market one rainy afternoon for groceries with the children carefully strapped and tucked into their car seats… safety belts secured around each one them and returning them home safely… intact – also very important… choosing the right early education program for one of those youngsters who is struggling to “keep up” in school – or maybe it’s a quality of life choice so very important to you personally like… choosing the surgeon who will repair a delicate to treat and painful spinal disc ailment that has caused you years of terrible suffering.

We regularly make decisions that affect our personal and family lives within the context of the times we are living in when we make them. We place our faith and trust in the professionals we select to advise us on these and other very important matters. These “coaches”, as I will continue to refer to them, are Physicians, Lawyers, CPA’s, Financial Investment Consultants, RealEstate Professionals, Insurance Experts, etcetera. These carefully chosen advisers keep us abreast of new opportunities for healing, financial growth and security while at the same time appraising us of the risks and dangers that occur minute to minute both over and under the world’s constantly changing landscape. When the unpredicted problem arises and a major problem will happen at least once in all of our lives, we might need to turn to the “law” – the law lives and breathes and changes by virtue of human, political and technical progress. Those “Coaches”, I mentioned earlier in this memo, also rely on legal experts to help them and their young as well as you and I who they might advise having been selected by one of “us” as a “coach”. We all in the final analysis, must navigate what is often a cloudy, murky, unsure world as part of survival in and of itself.

My legal “coach”… Cesar Gavidia, who has been helping me find my way in this unsure world, is a lawyer I’m very proud to know. After taking my troubling call about a serious insurance matter, Cesar immediately set about collecting the insurance policy information and after carefully studying the insurance policy language… language with which he was and is very familiar, gave me a “gift” that I cannot repay in kind… the “gift” was faith in the law and more importantly… faith in Cesar Gavidia. If you believe as I do, that a legal “coach” is needed to help flesh out your team of professional advisors… then consider talking to Cesar.

We live in a cynical world and we are all afraid of the “unknown”. Step into the knowledgable, kind, generous, professional world of “law” as practiced by Cesar… he really, really, really saved me. And although there are no absolutes… my insurance problems may need more care… a constant I can rely on and believe in is Cesar Gavidia. He will protect me by judiciously and honestly applying the “law”. As hard as it is to believe in anything we hear or read today… please believe me… because my still unfolding story just happens to be the unvarnished truth… and Cesar will get me through these insurance issues the right way, by employing the “truth” in the law… I just know he will… i just somehow know he will. Dan

***** 5 stars based on 202 reviews

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