A claimant has succeeded in getting a Federal Court to overturn a decision by Aetna to terminate benefits to a claimant who suffered from cancer and later from significant orthopedic conditions of the cervical and lumbar spine as well as depression. Aetna terminated the claim after a peer review, when a doctor is hired to review records only and the doctor does not examine or meet the claimant. On appeal of the terminated claim, Aetna again engaged various peer reviews, none of whom met or examined the claimant.
The Court determined that Aetna had improperly terminated benefits, finding that the support from the claimant’s physician was “sounder than those presented by the peer reviewers,” which the Court found were largely presented in conclusory fashion, making it unclear how they reached such starkly contrasting results from those of the claimant’s provider. Another factor leading the Court’s decision was Aetna’s failure to follow the recommendation of one of its peer reviewers to procure neurocognitive testing to assess the level of cognitive impairment, which led the Court to conclude that the basis of the opinions were lacking.
The Court thus granted benefits to the claimant for the own occupation portion of her claim, and remanded the claim back to Aetna for consideration of further benefits under the any occupation stage – a change in definition of disability in the claimant’s policy.
It should be noted that the standard of review in this case was de novo, which allowed the Court to substitute its judgment for the insurance company’s decision. Had this case been decided under the abuse of discretion standard of review, it is possible that the Court would have upheld the claim determination, as that standard largely adjudicates whether Aetna’s claim process was appropriate and whether there was some substantial evidence to support the claim determination, a much more favorable standard of review for insurance companies.
Carrier v. Aetna Life Ins. Co.