To Remand or Not to Remand: One Court's Opinion on When to Remand a Claim for Long Term Disability Benefits under an ERISA Aetna Policy

In a recent ruling in the case of Dupell vs. Aetna, which pertained to rights to long term disability benefits under an ERISA governed group disability policy, a West Virginia Federal Judge ruled that the ERISA based disability litigation before the Court should not be dismissed on Motions for Summary Judgment filed by Ms. Dupell or Aetna. Furthermore, the Court ordered that the case should not be remanded back to Aetna for further review, but rather go to trial on the merits.

Factual Overview of Aetna Long Term Disability Claim

In 2008, prior to filing a claim for disability insurance benefits under her employer provided group long term disability policy administered by Aetna, Ms. Dupell worked as a sales consultant in the construction industry. She had a long history of back pain resulting from discogenic and degenerative disc disease, which would eventually require surgery. Prior to filing for LTD benefits, it is interesting to note that in 2005, based upon her extensive medical history, she was deemed “incapable of substantial activity” by the Social Security Administration and began receiving Social Security Disability benefits. A testament to her desire to work, she began working as a sales associate on a trial work basis as permitted by the rules of the SSA. Prior to the end of the nine month trial period she was hired on a full time basis with the company from which she would file for the disability benefits that are the subject of this lawsuit. She continued to work for approximately two years before her medical conditions again prevented her from performing the duties of her occupation as a sales associate.

Ms. Dupell filed for long term disability insurance benefits in March of 2008 and was initially approved for benefits under the 24 month “own occupation” definition of disability. During this time, the Social Security Administration also reinstated her disability benefits retroactive to November 2007, after again determining she was incapable of work. Throughout the following 2 years she provided Aetna with objective medical evidence to support her ongoing complaints of pain, to include multiple MRIs, as well as undergoing various procedures in an attempt to control her pain. In March 2010, during an “any occupation” review for entitlement to continued benefits, Aetna determined that her conditions did not prevent her from performing any gainful occupation as defined by her Policy, effectively terminating her claim as of April 1, 2010.

Ms. Dupell appealed Aetna’s termination through an ERISA Appeal, providing Aetna with additional MRI evidence, letters of support from her treating physicians, and the results of an independent medical evaluation she underwent, which supported her inability to work at any level. However, in December of 2010, based on peer reviews conducted by Aetna’s doctors, none of whom ever physically examined Ms. Dupell, Aetna upheld it’s denial of her claim asserting a lack of clinical evidence to support functional impairment. In January of 2012, Ms. Dupell filed a long term disability lawsuit against Aetna. This claim was not handled by our law firm.

ERISA Disability Litigation Against Aetna: A Brief Overview

Long term disability insurance lawsuits against Aetna insurance company are fairly common experience. In order to understand the importance of the Court’s ruling in Dupell, it is important to have a general idea as to the nature of litigation under ERISA governed long term disability policies. Prior to even being able to file a lawsuit against an insurance carrier for a denial of benefits, ERISA requires that the claimant file an administrative appeal (also known as an ERISA Appeal) of the insurance carrier’s adverse determination. If you have ever received a denial letter, you are familiar with the common language of having “180 days to file an appeal.” Based upon the policy and procedure of the insurance carrier, a claimant may only have one opportunity to file an appeal. This appeal is essentially the final opportunity for a claimant to provide additional evidence of disability for, in the event that the Appeal is denied, no additional information can be added to the record. A final denial of benefits is commonly expressed in a denial letter with language to the effect that the claim is now closed and you now have the right to bring a civil action under ERISA.

What does it mean to bring a civil action under ERISA?

ERISA governed policies are under the sole jurisdiction of the federal courts and, as such, a lawsuit brought under ERISA must be filed in Federal Court. Unlike what is commonly depicted in TV shows and movies, the plaintiff (claimant) does not get the traditional “day in court”. The plaintiff does not get to sit in a witness stand and tell their story to a jury or even a judge. In ERISA lawsuits, there is no live testimony from the claimant or any of their doctors in 99% of the ERISA cases. The Judge’s review of the case is essentially limited to a review of the documents contained in the Administrative Record.

What do you have to prove at trial?

The burden of proof at trial under an ERISA governed policy is a case to case analysis based upon the language contained within the Policy and the governing jurisdiction of the Policy. Unfortunately for a large percent of claimants, many policies contain what is known as a Discretionary Clause which provides the insurance company with the right to interpret the Policy as it sees fit and affects a Court’s Standard of Review. Without getting into too much detail, a discretionary clause essentially provides the insurance company with the benefit of the doubt when a Judge reviews the company’s conduct and review of a claim at trial. If a discretionary language is contained in the disability policy, a Plaintiff has the burden of (1) proving they are disabled (based upon the information in the administrative Record) and then, and only then, (2) showing that the insurance company acted unreasonably in denying the claim. This is a general, layman’s rendition of the Standard of Review in an ERISA case.

What is a Motion for Summary Judgment?

Simply put, a Motion for Summary Judgment is a motion filed by either the plaintiff or the defendant in which they argue that their position is correct and that the court should rule in favor of one side or the other without the need for a trial. In the Dupell vs. Aetna case, both Ms. Dupell and Aetna filed Motions for Summary Judgment, both of which were denied by the Court. In denying these motions the Court opined that there existed an issue of fact with respect to the evidence in the case that required the matter to be resolved at trial.

In the instant case, Ms. Dupell made motion for the Court to remand her case back to Aetna. In doing so, she argued that Aetna had insufficient evidence to render a decision on her claim. Specifically, she argued that Aetna should have had a functional capacity examination performed to document her physical restrictions and limitations. Aetna argued in rebuttal, and the Court agreed, that the onus to prove disability was on Ms. Dupell and that Aetna had no duty to secure specific forms of evidence. The Court further noted that Aetna allowed her the opportunity to provide information to support her disability during the course of the appeal and that Aetna had sufficient evidence, to the tune of 41 documents, with which to review in rendering its decision. In turn, the Court denied Ms. Dupell’s motion to remand her case back to Aetna for further consideration.

What can we take away from this ruling?

This ruling reinforces the overwhelming importance of preparing and filing a strong ERISA appeal of a denial of disability benefits. We have received numerous calls from claimants whose claims have been denied after they have filed their own appeals. This dramatically hinders the ability of prevailing at trial as certain evidence that might have proven beneficial to support disability was not provided, and can no longer be added into the record. The Court in Dupell made it clear that, no matter how unfair it may seem, the duty to prove disability lies on the claimant and not the insurance company. In this case Aetna had no duty to have Ms. Dupell undergo a functional capacity evaluation even though it might substantiate her claim for disability. Ms. Dupell’s failure to undergo such testing on her own and provide the results of same with her appeal now prevents her from being able to present this potentially supportive information to the Judge at trial.

Every single claim for benefits is unique, as is every appeal. Following a denial of benefits, the appeal is the most important part of your claim, as it quite literally forms the basis of the evidence and information to be argued in the event of trial. It is crucial to provide any and all information to support the inability to work based on the requirements of the definitions contained in your policy. Failure to do so could potentially bar you from ever recovering benefits.

It should be noted that Dell and Schaefer does not represent Ms. Dupell, nor had any involvement at any point in her claim. Her case is still currently pending in the United States District Court for the Northern District of West Virginia.

Prior to filing an Appeal to an insurance company denial of benefits, it is highly recommended you consult with a disability insurance attorney as to your rights and options. Our firm has handled hundreds of claims against Aetna from the application stage through ERISA appeals and lawsuits. Please feel free to contact Attorneys Dell and Schaefer for a free consultation.