Disability Insurance Blog

Aetna Found Arbitrary and Capricious on Termination of Long Term Disability Insurance Claim


Tuesday, July 10th, 2012

A Federal judge in Ohio has determined that Aetna’s reliance upon well known insurance pandering doctors contributed to a finding that its termination of a long term disability insurance claim was arbitrary and capricious. Aetna relied upon a number of doctors that regularly perform paper only medical reviews for insurers, including Dr. Richard Kaplan, Dr. Philip Marion, and Dr. Elena Mendelssohn.

The Court took particular issue with Dr. Marion’s material mis-characterizations and omissions of the medical evidence in reaching the conclusion that the claimant could perform sedentary work. The Court also was troubled by the failure to consider the claimant’s whole person impairment, wherein Aetna chose to isolate the medical issues individually rather than considering the nature and scope of the collective impairment.

In light of Aetna’s financial conflict of interest, Aetna’s conduct was determined to be arbitrary and capricious, compelling the Court to reverse Aetna’s decision and remand the claim back for a proper review of the evidence.

The trend seen in the disability insurance claim industry is the excessive reliance upon paper only medical reviews, with insurers choosing not to secure an actual medical evaluation of a claimant, and instead, having doctors repeatedly render opinions on their behalf on the sole basis of documentation. If you are dealing with a similar situation, call us today, to see how we can assist in leveling the playing field.

Stephens v. Aetna Life Ins. Co.