A FederalJudge in New York has ordered Aetna to trial in an ERISA disability claim, afterdenying its efforts to have the Court grant judgment in its favor on a grouplong term disability insurance claim.
The Judgefor the Western District of New York determined that “having reviewed theevidence, this Court finds that the Administrative Record contains conflictingreports and opinions that must be assessed at trial concerning whether [theclaimant] continued to be disabled from performing ‘any reasonable occupation’under the Plan”.
The Courtfurther stated that “because determining whether [the claimant] continued to bedisabled under the Plan requires the weighing of competing medical opinions andassessment of credibility, neither side is entitled to summary judgment”.
To supportits decision, the Court noted how the need to weigh competing medical opinionsand credibility simply could not be resolved through the summary judgmentmechanism.
Each side had developed medical opinions. Aetna’s opinions were based solely upon a review of the medical records, rather than any physical examination conducted.
This is a commonly seen tactic from Aetna, one that has been recognized by numerous courts who have chastised Aetna for using doctors who “have their bread buttered” by Aetna (See Maiden v. Aetna).
Because the policy and plan governing the claim did not contain discretionary language to afford Aetna a more favorable standard of review, the Court reviewed the matter de novo, rather than under the abuse of discretion standard of review.
This becamemore favorable to the claimant, in demonstrating entitlement to benefits andovercoming Aetna’s claim determination. The Court noted a number of cases from within the Second Circuit whichnoted that “it is inappropriate for a court to grant summary judgment where theresolution of an ERISA benefits dispute entails adopting one medical expert’sopinion over another’s.”
The Court citedboth Tretola v. First UNUM Life Ins.and Napoli v. First UNUM Life Ins.,as authority for its determination that summary judgment was not appropriateunder this significant dispute medically.
Bennett-Brady v. Aetna Life Ins. Co.