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Aetna Conducted Unreasonable Review of Disability Claim

Miguel Mendez worked for FedEx for over 25 years and was covered by a long-term disability plan administered by Aetna. As a result of a motorcycle accident, he suffered numerous injuries including severe orthopedic injuries and a brain injury. Aetna initially approved Mr. Mendez’s claim for short term and long term disability benefits and made payments for two years, but eventually terminated the individual’s benefits claiming that he no longer met the definition of disability.

Mr. Mendez appealed the termination of benefits and as part of the appeal, Aetna submitted medical records from his doctors to their own physicians for a file review. The physicians did not request an in-person examination and they found that the medical evidence did not support a total disability. Thus, Aetna confirmed its termination of disability benefits.

The Michigan court found that there were several issues during the process that showed that Aetna’s decision was unreasonable. First, the court highlighted Aetna’s failure to conduct an in-person evaluation, but instead relied only on file reviews. While the court recognized that there is nothing incorrect about a file review, it found that the failure to conduct a physical examination raises questions about the accuracy of the benefits determination. In this case, the claimant is complaining of severe pain and for Aetna to imply that Mr. Mendez’s complaints of pain lacked credibility but not conduct an in-person examination was unreasonable.

Second, the Court noted that the reviewing physicians have a vested interest in finding there is not a total disability. These physicians are repeatedly used by the insurance company’s and thus have a conflict of interest when making their determinations.

Lastly, the court emphasized Aetna’s failure to adequately explain why the Social Security Administration’s decision to award Mr. Mendez benefits should be distinguished from their determination of benefits. The court held that Aetna was not justified in ignoring the Social Security Administration’s decision to approve the individual’s social security benefits just because the standards regarding social security determinations are different. The court stated that Aetna should have explained why they reached a different determination than the Social Security Administration.

This case is a good example of how insurance companies can be unreasonable and wrong in their review of a claim file. If you feel your claim was unreasonably denied, contact the experienced attorneys at Dabdoub Law Firm for an evaluation of your case.