A Federal Judge in New York has ordered Aetna to trial in an ERISA disability claim, after denying its efforts to have the Court grant judgment in its favor on a group long term disability insurance claim.
The Judge for the Western District of New York determined that “having reviewed the evidence, this Court finds that the Administrative Record contains conflicting reports and opinions that must be assessed at trial concerning whether [the claimant] continued to be disabled from performing ‘any reasonable occupation’ under the Plan”.
The Court further stated that “because determining whether [the claimant] continued to be disabled under the Plan requires the weighing of competing medical opinions and assessment of credibility, neither side is entitled to summary judgment”.
To support its decision, the Court noted how the need to weigh competing medical opinions and credibility simply could not be resolved through the summary judgment mechanism.
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 became more favorable to the claimant, in demonstrating entitlement to benefits and overcoming Aetna’s claim determination. The Court noted a number of cases from within the Second Circuit which noted that “it is inappropriate for a court to grant summary judgment where the resolution of an ERISA benefits dispute entails adopting one medical expert’s opinion over another’s.”
The Court cited both Tretola v. First UNUM Life Ins. and Napoli v. First UNUM Life Ins., as authority for its determination that summary judgment was not appropriate under this significant dispute medically.
Bennett-Brady v. Aetna Life Ins. Co.