Evidence Of Disability, Conflict Of Interest Hurt Aetna

Evidence of disability and conflict of interest and are the two main reasons Aetna was forced to reverse its termination of benefits. In a recent case out of North Carolina the court found that Aetna acted unreasonably in terminating the claimants long term disability benefits.

The claimant, Ms. Montero, was a business support manager for Bank of America. She suffered from fibromyalgia-related pain and fatigue. She ultimately had to leave her job and filed for long term disability benefits. Aetna initially granted Ms. Montero’s claim for disability benefits. However, after 18 months, when the definition of disability in the policy changed they terminated the benefits.

Aetna based its decision on reports which found that Ms. Montero’s evidence of disability did not support her claim that she could not work. Ms. Montero appealed, providing statements from her husband, her attorney, and her treating physicians. Each one spoke to the chronic pain and fatigue she suffered as the result of her fibromyalgia diagnosis. Aetna denied her appeal. Ms. Montero filed a lawsuit challenging Aetna’s decision to terminate benefits.

The court found that Aetna acted unreasonably in terminating Ms. Montero’s benefits based on two main issues: (1) Aetna did not properly consider the proof of her disability; and, (2) Aetna had a significant conflict of interest.

First, the court found that Aetna failed to properly consider or counter Ms. Montero’s evidence of disability. The court noted that given the subjective nature of fibromyalgia, Ms. Montero submitted the best proof she could to prove her condition and symptoms. According to the court, once she submitted this evidence, Aetna then had the burden of presenting proof contradicting her claim. The court found that Aetna failed to do so.

According to the court, rather than rebutting Ms. Montero’s evidence, Aetna relied solely on the opinions of its four peer reviewers. The reviewers never met with Ms. Montero. The court noted that an independent medical examination or surveillance would have been a better way to challenge Ms. Montero’s proof of disability.

The second factor the court highlighted was Aetna’s significant conflict of interest. Aetna encouraged Ms. Montero to apply for SSDI benefits. They even offered to pay to have another company represent her. By doing so, Aetna was acting in its own economic interest. If she received SSDI benefits, her monthly benefit payment from Aetna would be reduced by the amount she was receiving from SSDI.

While she was filing her social security administration claim, Aetna was reviewing Ms. Montero’s long term disability insurance claim. They went through it even though they were ultimately going to terminate her benefits. Aetna told the company representing her SSDI claim to continue representing her. Again this seems to be motivated by Aetna’s own economic interests. If Ms. Montero’s SSDI benefits were granted, Aetna could recover back payment for benefits already paid.

The Court noted that Aetna encouraged another company to represent her disability claim to the social security administration, while they were denying the same disability claim. They supported the other company in saying she was disabled from fibromyalgia. Yet they found, for their own benefit, that she was not. That is a conflict of interest.

The court ordered Aetna to reinstate Ms. Montero’s long term disability benefits and pay prejudgment interest and attorney’s fees.