Our client is a 59 year old male with a disability policy from Aetna. He worked as a CFO for a mid-sized company and came to us when Aetna had denied his coverage. Aetna claimed that his mental health issues were subject to a pre-existing claim limitation, and therefore he was not eligible for disability benefits.
Our first step was to work with his treating physician to decipher information and timelines for his prior diagnosis, care and treatment and his current impairing condition. By digging deep into the details, we were able to clearly distinguish the prior diagnosis and treatment – from the look-back period of the pre-existing issue – from his current condition. We succeeded on that issue, getting Aetna to agree that the two conditions were not related and the pre-existing claim limitation did not apply to our client.
Even with that issue corrected, Aetna was not rushing to put him on claim. The next round centered on Aetna’s challenging the severity of his impairment. Despite the large amount of medical records that proved that there had been no changes in his condition, Aetna still refused to put him on claim. Through continued battle, we were able to get Aetna to pay a portion of his benefits, but they refused to accept the full liability of claim, asserting that his condition had improved.
In a strategy that we have seen time and again, Aetna secured an internal medical review with a frequently utilized psychologist who opined that our client’s condition was not so severe as to make him unable to work, despite its previous admission for a closed period that he was impaired.
We then developed a responsive rebuttal, attacking the in-house medical reviewers’ qualifications, bias and the substance of her findings. We worked with our client’s psychiatrist and psychologist in developing additional medical evidence to support payment of the benefits. We attacked both the substance of their review and the bias involved in the claim handling, and Aetna ultimately capitulated and agreed that our client was in fact disabled and entitled to benefits, and advanced the full 24 months of benefits available under the policy in a single payment.
Mental health claims are particularly precarious, and given the typical short period of coverage time, can become extremely trying for policy owners. If you have a mental health claim and your disability insurance company is challenging your claim, call our office at 877-LTD-CLAIM (877-583-2524) to learn how we can help.