IS AETNA’S SALE TO HARTFORD BEHIND ITS CLAIM HANDLING CONDUCT?
Tuesday, December 5th, 2017
A recent decision by a Federal Judge in North Carolina supports such a line of thinking. Here, the Court determined that Aetna failed to properly consider subjective evidence (a common theme of Aetna), as well as providing “scant attention” to the supportive medical evidence. Here, the claimant, a commercial pilot, was suffering from significant orthopedic problems, supported by testing results. Aetna denied the claim, asserting that the medical evidence did not support the inability to perform the material duties of his own occupation. Despite significant additional medical evidence being submitted on appeal, Aetna continued to refuse to accept liability.
The Court was asked to determine the matter upon competing motions for judgment. The Court determined that Aetna’s “decision making process was not reasoned and principled and relied upon materials inadequate to constitute substantial evidence to support its decision.” In reaching this decision, the Court noted that “subjective evidence is not only relevant, but may sufficient in itself to support the claim.” Further, the Court stated that “to discount such evidence as Defendant does demonstrates an errant process.” As discussed by the Court, the “failure to lend weight to the subjective evidence or explain its role in Defendant’s decision led to an unreasonable decision to deny benefits.”
The Court also determined that Aetna’s financial conflict of interest was significant. After noting that conflicts are but one factor to give consideration to in deciding these ERISA cases, the Court determined that Aetna’s claim handling conduct, as noted above and within the decision, supported a finding that the conflict was significant.
Based upon the significance of the Court’s findings, the Court awarded as a remedy reinstatement of all outstanding disability benefits, prejudgment interest on this retroactive benefit payment, and costs and attorneys fees to be awarded to plaintiff.
Cline v. Aetna Life Ins. Co.