AETNA Reverses Termination Decision on Appeal

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AETNA Reverses Termination Decision on Appeal

For claimants who have read the doom and gloom all over the Internet about how difficult it is to win against insurers — some good news. We recently appealed AETNA’s decision to terminate our client’s LTD benefits and they reversed themselves.

Why did our client prevail?

Candidly, he prevailed because he engaged a competent ERISA lawyer to prosecute his appeal. Too many claimants call our firm to discuss the denial/termination of their LTD benefits and they do so AFTER the final appeal decision has been made. This blog won’t address in detail why that is such a bad decision, but suffice to say, your appeal is the ONLY opportunity you’ll have to make your best case. An experienced ERISA lawyer knows he has one shot (generally) to overcome the insurer’s decision. At the risk of appearing self-serving, claimants should call an experienced ERISA lawyer to prosecute an appeal of an adverse claim decision.

Our client did and AETNA had little choice but to reverse itself based on the evidence.

The client had long suffered from lumbar disc disease and was also diagnosed with cervical disc degeneration. He had undergone five back surgeries and tried a spinal cord stimulator implant to address or resolve his chronic pain. AETNA approved his claim for LTD benefits under an “own occupation” definition of disability and suggested he apply for Social Security disability benefits.

Later, AETNA began to reevaluate our client’s claim under the “any occupation” definition of the policy. It arranged for our client to be subjected to a functional capacity evaluation. As reflected in the record, however, the FCE was a ”short FCE” conducted by a physical therapist rather than a qualified physician (which in this case was a violation of the applicable Plan). The short FCE tested for matters which were meaningless to the question of our client’s ability to engage in sustained work activities every workday. The value of the short FCE was significantly diminished because it did not provide prolonged or subsequent day observation. At best, it was an extrapolation based on a single episode, limited time frame encounter with our client.

AETNA received the FCE report and said it fails to support functional impairment. It used the FCE to conduct an employability assessment. As they say, ”garbage in, garbage out.” Suddenly, according to AETNA, our client could perform work in several sedentary to light occupations and the medical documents did not support totally disability under the any occupation definition.

We prosecuted the appeal and in so doing obtained the entire claim file. We noted and called out the procedural irregularities in the claim handling process. We highlighted the self-serving behavior of AETNA’s claims personnel in deciding to terminate benefits. We specifically noted the objective evidence in the form of physical examinations, MRI’s, and x-rays which supported the opinions of our client’s treating physicians as to his functional limitations.

We gathered and submitted medical records confirming our client’s spine abnormalities, pain, and related treatment. We presented the results of a consultative examination confirming significant range of motion restrictions and pain in our client’s lumbar and cervical spine. Our appeal letter and submissions truly could only lead to one reasonable conclusion — our client had been continuously unable to work in any occupation since his disability onset date.

If you’ve been denied disability benefits or had your previously-approved benefits terminated, don’t give up. We might be able to help.