AETNA CLAIM DECISION LACKS SUBSTANTIAL EVIDENCE
Monday, April 4th, 2011
A Federal Judge has demonstrated that despite a favorable standard of review for an insurance company, a claim decision must be supported by substantial evidence, or it will be reversed. Aetna reached a claim determination on the purported basis of medical reviews performed by its in house physician and an outside physician consultant, neither of whom examined or evaluated the claimant.
The Court carefully considered the substance of the reports relied upon by Aetna, and determined that these reports lacked substantial evidence, due to the selective inclusion of information, and the failure to consider support for the impairment from the claimant’s treating medical providers, coupled with the mischaracterization of the medical findings by another hired physician.
The Court noted the value of a physical examination to a reliable assessment of a claimant’s disability. The Court chastised Aetna for searching for a reason to deny benefits, where Aetna blindly accepted the paper review conclusions over the opinions of treating physicians, without meaningful explanations as to why.
Unfortunately, this decision is more the exception than the rule, and all too often, insurers are permitted to engage in like conduct, without meaningful scrutiny by the Courts. Often, the courts determine that it was appropriate for an insurer to rely upon these “independent” physicians, or even to rely upon in house doctors who do not even practice medicine on patients, fail to conduct an examination of the claimant and demand objective evidence, even where the policy does not contain such a requirement.