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Aetna Unfairly Denied Short Term Disability Benefits to Home Depot Employee with Narcolepsy

A federal court in Nevada found Aetna unfairly denied a Home Depot employee’s claim for short-term disability benefits. The court found Aetna had effectively deprived the claimant of the ability to appeal when it quickly denied his initial claim without receiving medical evidence.

In November of 2015, Mr. Speca became disabled due to falling asleep unpredictably and uncontrollably. Unable to work, Mr. Speca filed a claim for short-term disability benefits on November 07, 2015. The following is a timeline of events that followed the submission of his claim:

  • 11/09/15 - Aetna was unable to reach Mr. Speca by phone.
  • 11/09/15 - Aetna requested medical records from Mr. Speca’s doctors.
  • 11/13/15 - Aetna was unable to reach Mr. Speca by phone.
  • 11/13/15 - Aetna sent a letter to Mr. Speca advising him that if he did not call back within 7 days his claim would be decided based on the information gathered by Aetna.
  • 11/16/15 - Mr. Speca placed a call to Aetna (i) requesting a different representative as he could not understand the messages that were left for him and (ii) informing Aetna of another treating provider.
  • 11/16/2015 – A different representative called Mr. Speca but could not reach him. The representative left a message stating Aetna needed help gathering the medical records.
  • 11/20/2015 – Aetna denied Mr. Speca’s claim stating he did not submit, nor was Aetna able to obtain, any medical evidence of disability.

Mr. Speca appealed the denial of benefits, introducing medical evidence of disability. Aetna denied his appeal. Accordingly, Mr. Speca filed a lawsuit for his short-term disability benefits.

The Court’s Review of Mr. Speca’s Claim

Standard of Review

Like most claims for disability benefits, Ms. Speca’s claim was governed by the Employee Retirement Income Security Act of 1974 (ERISA). Generally, if you are eligible for disability benefits through your job, it is likely governed by ERISA.

Most disability policies contain discretionary language. This means insurance companies, including Aetna, have discretion to determine if someone is disabled. Under ERISA, if a plan document includes discretionary language, the court will apply an arbitrary and capricious standard of review. Under this standard the court can only rule in your favor only if it finds the insurance company had no reasonable basis to deny benefits. This is a difficult standard to meet.

Here, the disability policy did not contain the necessary discretionary language. Therefore, the court did not need to give deference to Aetna. This greatly increased Mr. Speca’s chances of success. Our experienced lawyers can help you better understand your disability policy and which standard of review applies to your claim.

The Court’s Decision

The court found Aetna was wrong in initially denying Mr. Speca’s claim for the following reasons:

  • It had not yet received the records it requested from Mr. Speca’s doctors
  • Nothing in the policy required a decision within 14 days as argued by Aetna
  • Aetna never informed Mr. Speca that his claim would be denied if he did not submit medical records by November 20, 2015

The court ultimately concluded Aetna acted unfairly in denying Mr. Speca’s claim on the basis of not having received any medical records, particularly when Aetna had requested records from two doctors identified by Mr. Speca. The court argued Aetna should have waited a few more days for those records.

The court also found that by quickly denying Mr. Speca’s initial claim, Aetna took away his ability to appeal. The court held that Aetna’s appeal denial effectively served as an initial denial of the claim. Thus, the court remanded this case back to Aetna and asked that they allow Mr. Speca another opportunity to prove his disability.

Help from an Attorney with Expertise in Disability Insurance

Disability insurance law is complicated. If your claim for disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.

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Because federal law applies to most disability insurance claims, we do not have to be located in your state to help.

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