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New York Federal Court Orders Aetna to Pay Long Term Disability Benefits

In Dunda v. Aetna, Aetna terminated plaintiff’s long term disability benefits even though there was no medical evidence that her disabling conditions had improved since it granted her long term disability benefits. The plaintiff, a former general store manager for the Wawa corporation, suffered from a number of conditions which caused her debilitating low back pain: lumbar herniated nucleus pulposus, a herniated disk and sciatica. She was initially granted short term disability benefits when she could no longer work in her own occupation. Long term disability benefits were then awarded when medical evidence supported her claim that she was disabled from performing any reasonable occupation.

After two years on disability under the “any reasonable occupation” standard, Aetna terminated her benefits on the ground that there was no objective evidence of her disabling medical condition. Aetna did not consider her SSDI award nor did it conduct an independent medical exam (IME). On these facts, the New York court found Aetna’s termination of benefits was arbitrary and capricious.

Reviewing Court is Not Bound by Stipulation Concerning Standard of Review

The court first dealt with the parties earlier stipulation that the proper standard of review was for an abuse of discretion. The plaintiff back-pedaled and argued she should not be bound by the stipulation, whereas Aetna wanted the court to enforce it. The court ruled: “This Court is effectively sitting as an appellate court, and therefore is ‘not bound by stipulations as to questions of law.’” It determined that the appropriate standard of review was whether or not Aetna acted in an arbitrary and capricious way when it terminated plaintiff’s benefits.

Aetna’s Actions Were Arbitrary and Capricious

The court found Aetna’s termination of long term disability benefits was arbitrary and capricious for several reasons:

Although remand would generally be the remedy in a case like this one, the court held that, “no new evidence could produce a reasonable conclusion permitting a non-arbitrary denial of the claim. Remand would, in this case, be a useless formality.” The court ordered Aetna to reinstate benefits effective retroactively to the date benefits were terminated.

This case was not handled by our office, but we believe it is instructive for those whose long term disability benefits are terminated even though there has been no change in their medical condition. If you are having a similar problem, or have any issue concerning your disability benefits, contact one of our experienced disability attorneys for a free consultation.

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Questions About Hiring Us

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   *****

Terri E. (Maryland)

The process has been exactly how I had hoped it would be. Disability is a scary, unfriendly process, even for those of us who have worked in the claims administration area. It seems to be designed to deny benefits with complicated rules, burdensome documentation requirements, and constant requests for information to the beneficiary and my doctors. As a patient/beneficiary, you can feel like you are all alone and that you spend too much time jumping through hoops for the disability provider.

After a few months of doing it myself, I realized I wanted an advocate who could advocate for me with the provider and answer all of my questions on the Erisa process and rules. I interviewed one attorney in Maryland who was actually adversarial with me (his future client) so it was an awesome breath of fresh air when I interviewed Stephen Jessup. He was polite, extremely knowledgeable, upbeat, and calm! He helped me to understand the process and where I stood in it.

He and Vanessa communicate and keep me apprised of events within my case and make recommendations on actions I should take to proactively help my case win approval (e.g., Functional Capacity Evaluation). They are truly my safety net and well worth every penny because they help manage the disability provider and my doctors as well as ensuring I am on track in the process. I don’t think I would have survived this without them.

***** 5 stars based on 202 reviews

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