A Federal judge in West Virginia has overturned Aetna’s termination of a long term disability insurance claim for a claimant who had been paid his disability benefits for several years. The Court determined that the claim for disability benefits should be paid, with interest on the benefit arrears, and that Aetna must continue to pay the claim until such time as the claimant recovers or is no longer entitled to disability insurance benefits under the policy.
The claimant became disabled in 2008, when he stopped working due to chest pain, which led to a triple bypass, and subsequent artery graft. The claimant also suffered from back pain and was obese. He was under the care and treatment of numerous medical providers for his various co-morbid conditions. Aetna had a paper review conducted, which found no functional impairments. They then conducted a vocational assessment which relied upon their paper medical review. Aetna then had an examination performed, and the examiner opined that the claimant could work in a sedentary occupation.
Aetna terminated the claim on the basis of the claimant’s functionality and employability. On appeal, Aetna had a paper medical review conducted, which found no functional limitations and the termination was upheld by Aetna.
The Court was troubled by Aetna’s reliance upon the report from the examining doctor, who first stated that the claimant could only work part time, but that after a short period of weeks, would be capable of full time employment. Noting the heavy pain medications taken by the claimant, his co-morbid conditions and the length of time he had been out of work, the Court found Aetna’s reliance upon the examiner’s opinions to be unreasonable.
Thus, benefits were reinstated and interest awarded.
Bird v. Aetna Life Ins. Co.