The reliance upon conclusory opinions of non-examining medical reviewers did not support Aetna’s claim determination, according to a Federal Judge in Michigan. The Court took issue with Aetna’s embrace of these hollow opinions, which were strongly contradicted by the claimant’s treating doctors, each of whom clearly opined that the claimant was unfit to work, on the basis of clinical evidence and direct observation.
Further supporting its decision, the Court noted that Aetna failed to explain why it arrived at a different conclusion than the Social Security Administration, other than to note that Social Security relies upon different criteria. The Court was troubled by this lack of meaningful consideration, along with the wholesale adoption of the paper reviews, which were not based upon any examination or evaluation of the claimant.
Accordingly, the Court reinstated benefits.
Fura v. Federal Express Corp. LTD Plan