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Pennsylvania Court Awards Long Term Disability Benefits To Claimant, Finds Aetna Abused Discretion By Failing To Consider Self-Reported Symptoms

Attorney Gregory DellAuthor: Attorney Gregory Dell

The claimant in this case, Ms. K, went on short term disability leave after developing anxiety and fatigue upon returning from maternity leave. She received treatment from her psychiatrist and eventually returned to work. When she returned to work, she was informed that she was required to increase her work week from 25 hours to 40 hours. Immediately thereafter, she suffered an increase of panic and resumed her STD leave. She began treating with a licensed clinical social worker, in addition to her regular psychiatrist.

Once Ms. K’s short term disability benefits were exhausted, she submitted her claim for long term disability benefits. Upon review of the information provided in support of her claim, Aetna denied Ms. K’s claim for LTD benefits. They informed Ms. K that the information in her file showed “limited and inconsistent findings” regarding her diagnosis of agoraphobia and panic disorder. Additionally, Aetna determined that the records “did not provide sufficient exam findings” to indicate impairment and that her symptoms “did not meet the impairment determination protocol for panic disorder.” Aetna further stated that the medical documentation did not explain how Ms. K’s functional impairment would preclude her from performing her occupation.

Ms. K appealed the denial and submitted to Aetna letters which explained the severity of her symptoms. Her LMHC submitted a letter to Aetna providing additional information regarding Ms. K’s symptoms and how they limit her ability to work. Ms. K’s psychiatrist also submitted a response to Aetna’s follow-up questionnaire documenting her symptoms, treatment, prognosis and barriers to improvement.

On appeal, Aetna had an “independent consulting peer physician” board certified in psychiatry perform a review of paper records. The peer review psychiatrist determined that the records did not contain any Mental Status Examinations, lacked objective test results, did not explain how Ms. K’s symptoms prevented her from performing her occupation, and that the described symptoms were not consistent with a DSM-IV diagnosis of panic attacks. Additionally, the peer review psychiatrist opined that Ms. K’s medicinal dosage was too low and “inconsistent with the proclaimed severity of symptoms and impairment in functioning.” Based on the peer review, Aetna denied Ms. K’s appeal.

Ms. K then requested that the denial of her appeal be reconsidered and submitted further documentation to Aetna. She submitted another letter further explaining discrepancies in the denial of her appeal. Her LMHC submitted to Aetna another letter detailing Ms. K’s panic attack and agoraphobia symptoms, situations that triggered her symptoms, and how the impact of her symptoms prevent her from functioning in her occupation.

Aetna re-reviewed Ms. K’s file and had a second independent peer psychiatrist perform a review of the paper records. The second psychiatrist determined that functional incapacity was not supported by objective medical evidence in that there was a lack of Mental Status Examinations, the psychotherapy notes lacked objective data, and there was an absence of hospitalization or intensive outpatient care. He stated that the data was almost “exclusively subjective and self reported [sic].” Based on the opinions of the second peer psychiatrist, Aetna issued its final denial of Ms. K’s claim for LTD benefits. Subsequently, Ms. K filed a disability lawsuit under ERISA. Our law firm did not handle this case.

Upon review of the administrative record, the Court found that Aetna’s decision to deny benefits was arbitrary and capricious for the following reasons:

1. The independent peer review psychiatrists failed to consider or credit the findings and opinions of Ms. K’s treating psychiatrist and licensed mental health counselor, nor did they consider or credit the subjective medical evidence

Although the case law well establishes that a plan administrator is not required to give special weight to the opinions of a claimant’s treating physicians, it also is not permitted to arbitrarily refuse to credit reliable evidence, including the opinions of treating physicians.

The second peer review psychiatrist, Goldman, opined that psychiatric functional incapacity was not supported by objective data and that this is based on the lack of detailed Mental Status Examinations, lack of objective data contained in the treating providers’ notes and absence of hospitalization or intensive outpatient care. He gave no credit to the determination of Ms. K’s treating psychiatrist and LMHC that she was not able to work, and he gave no credit to Ms. K’s self-reported symptoms. Rather he concluded that the lack of information indicates that Ms. K was not precluded from performing her job. However, Goldman did not mention that the psychiatrist documented Ms. K’s GAF scores of 40 and 50 (indicating serious impairment in social, occupation or school functioning). He did not mention that the psychiatrist recommended that Ms. K reach a GAF score of 60 before returning to work. He did not mention that the LMHC sent multiple letters to Aetna stating that Ms. K would be unable to perform the duties of her job if forced to return, or the letter which listed Ms. K’s panic attack symptoms that placed her within the recognized criteria for a panic attack diagnosis. Nor did he mention the psychiatrist’s letter indicating that she would be unable to work due to the specific ways her job functions would be impaired.

The first peer review psychiatrist, Sohn, not only did not give any weight to the opinions of Ms. K’s treating psychiatrist and LMHC, but she selectively picked information from the records on which to base her conclusions, and specifically omitted medical evidence that was contrary. For example, Sohn documents that Ms. K was given a GAF score between 40 and 70 and notes that a GAF score of 70 reflects mild symptoms, and generally functioning pretty well. However, she failed to report that a GAF score of 40 indicates major impairment. She also picked out certain notes from the treatment records that indicated Ms. K’s “depression/sadness clearing”, that Ms. K “went to two interviews”, and “got thru Aiden’s birthday with 35 adults.” However, Sohn failed to include the other parts of those same notes which indicated that Ms. K was not doing well at work, was “panicky and tearful – will pursue [medical leave of absence]”, felt “wiped out, weepy, dizzy…fears triggered when socially on the spot”, “felt exhausted”, and her reports that she still had “lots of fears.”

Sohn also specifically noted that her medication doses were too low which was inconsistent with Ms. K’s “proclaimed severity of the symptoms and impairment in functioning.” However, neither Sohn, nor Goldman or Aetna, addressed Ms. K’s follow up clarifying that she was placed on low doses because she was breastfeeding her infant. Instead, Aetna tried to argue that Ms. K “elected” to nurse her child and not take the proper dosages of her medications which lead to her condition not stabilizing like it would have had she taken the higher doses of the medications.

1. Aetna failed to address how Ms. K was expected to perform the duties of her job

Because the administrative record did not contain the job description that Aetna and its peer review psychiatrists used in their reviews, the Court based its description of Ms. K’s job on the work-related incidents contained within the records, as well as Ms. K’s description of the functions of her job provided for Aetna’s work history questionnaire. The Court concluded that her job entailed some collaborative, and possibly supervisory, role with co-workers.

Ms. K was diagnosed with panic attacks and agoraphobia. Ms. K and her treating psychiatrist and LMHC all provided information to Aetna that she was not able to grocery shop, take her daughter for ice cream, could not order from a fast food restaurant even if via the drive through window, had difficulty taking her children to day care and had difficulty just leaving her home. In these situations, Ms. K would suffer with increased heart rate, her body and hands would shake, breathing became labored, she became lightheaded and then would suffer a severe headache. The administrative record reflected that her employer stated she was not able to work from home due to budget concerns and, even if she was allowed to work from home, her position required her to still come in to the office regularly.

Despite the evidence which reflected how Ms. K was unable to function in a social setting, Aetna failed to address how it expected her to perform the material duties of her job over an 8-hour work day.

2. Aetna failed to conduct an independent medical examination (IME)

The Plan permitted, but did not require, Aetna to conduct an IME of Ms. K. Rather, Aetna opted to rely on reviews of the paper medical records by non-examining psychiatrists. The Court determined that in this case, because the decision to deny benefits was based heavily on a lack of objective medical evidence, the “prudent measure would have been to conduct an IME to assess the rather strong subjective evidence of disability.”

Based on all of these factors, the Court determined that Aetna’s decision to deny Ms. K’s claim for long term disability benefits was not reasoned or based on substantial evidence. Rather, the decision was arbitrary and capricious. The Court determined that it was appropriate to award retroactive benefits, as well as interest on unpaid benefits. Ms. K also requested an award of attorney’s fees and costs, but the Court deferred ruling until briefs on this issue can be considered.

If you have questions regarding your claim for disability benefits, or if your disability claim has been denied, feel free to call Disability Attorneys Dell & Schaefer for a free consultation.

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