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Aetna’s Decision Lacks Substantial Evidence to Support Termination

Wednesday, October 23rd, 2013

A Federal Judge in Maine has ruled that Aetna’s decision to terminate a long term disability insurance claimant’s benefits was lacking in substantial evidence to support the decision. As a result, the Court ordered the claim to be further reviewed, following a remand from the Court, and consideration of an award of attorneys’ fees against Aetna.

The Court reviewed the history of the claim handling, and outlined how and why it determined that Aetna’s decision was improper. The claimant, who suffered from Lupus, and the resulting symptoms, restrictions and limitations of that disorder, including fatigue, and concentration issues, along with secondary depression, saw his claim terminated after 24 months of benefits, on the purported basis that he could engage in some occupation, a definition of disability that governed following 24 months of benefits.

Following the termination of the long term disability insurance claim, the claimant filed an appeal, and provided additional support for his ongoing impairments. Aetna rendered its final determination, upholding the termination of his claim, and compelled him to file a lawsuit to secure any relief. The claimant filed a lawsuit, and the Court’s evaluation of the evidence revealed that Aetna relied upon “faulty reasoning or mis-characterization of the medical record” for its conclusion. The Court took issue with the conclusory and unsupported statement by one of its hired doctors that the claimant “simply lacked motivation and drive”, noting that this appeared to be reductionist to the point of being unreasonable, when viewed against the reports provided.

The Court was also troubled by Aetna’s mis-characterization of the record as it pertained to the claimant’s treating doctor, where it claimed that the doctor agreed with the conclusions of no disability provided by Aetna’s hired doctor. The Court held that it was a stretch to make that conclusion, and was not fair to characterize the claimant’s physician’s opinions as such. The Court held that Aetna’s flawed review process “permeated its entire review process” and “undermines confidence in its conclusions.”

Despite such a strong indictment of Aetna, the Magistrate Judge determined that a remand was the most appropriate remedy, essentially providing Aetna with the ability to engage in similar conduct again.

Grosso v. Aetna Life

Justin C Frankel

Written By:

Justin C. Frankel - Disability Insurance Attorney

Justin Frankel is a founding partner of the disability insurance law firm Frankel & Newfield and is a highly skilled litigator and advocate. He has published numerous articles on the challenges facing clients with private or individual disability insurance policies and those who own group or ERISA disability insurance policies.

Learn more about Justin | See Justin’s Publications



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