A Computer Engineer wins his lawsuit against Aetna Life Insurance Company for continued payment of long-term disability (“LTD”) benefits. A California district court found the medical evidence showed loss of functionality resulting in Mr. Cohen’s disability.
Before his disability, Mr. Cohen worked as a Computer Systems Engineer for STEC, Inc. One of his employee benefits was LTD coverage. The LTD policy was issued by Aetna and provided a monthly benefit should Mr. Cohen become totally disabled.
The LTD Policy
The LTD policy defined Totally Disabled as follows:
- For the first 24 months – you are not able, solely because of injury or disease, to perform the material duties of your own occupation
- After the first 24 months – you are not able, solely because of injury or disease, to work at any occupation
Mr. Cohen’s Claim
Mr. Cohen suffered significant injuries after crashing head-first into a wall while driving a Go-Kart. Injuries included traumatic brain injury, spinal cord compression, and an exacerbation of prior neck issues, all resulting in chronic pain.
Physical impairments from his accident made it so he could no longer engage in a full-time work. Thus, he filed a claim with Aetna for LTD benefits. Aetna found Mr. Cohen disabled and paid LTD benefits for over 9 years. Aetna repeatedly reviewed Mr. Cohen’s continued eligibility for benefits during these 9 years and always found him disabled.
In 2018, Aetna changed its mind and terminated Mr. Cohen’s benefits claiming he could do some full-time work. Its decision was based upon a medical examination performed by a hired physician, a medical records review completed another hired physician, and surveillance taken of Mr. Cohen. Mr. Cohen appealed Aetna’s sudden termination of benefits and submitted additional evidence of disability, including updated medical records and a vocational analysis.
Aetna denied Mr. Cohen’s appeal. Thus, Mr. Cohen filed a lawsuit against Aetna.
The Court’s Decision
The court ruled in Mr. Cohen’s favor, finding that he was totally disabled under the disability insurance contract because he could not physically perform full-time work. In its review of all the medical evidence, the court found Mr. Cohen proved he was restricted from performing full-time work. The court found the following persuasive evidence of total disability:
- Diagnoses of cervical disc disease, thoracic outlet syndrome, Raynaud’s syndrome, degeneration of several discs
- Mr. Cohen’s doctors’ opinions that he was only capable of working 4 hours per day
- A vocational analysis confirming there were no jobs that Mr. Cohen would be able to perform in
On the other hand, the court was not persuaded by the arguments set forth by Aetna. Namely, the court found that Aetna’s own reviewing physician identified restrictions that actually resulted in Mr. Cohen’s total disability. Also, the court was not moved by surveillance of Mr. Cohen engaging in every activities. The court stated that there is a difference between performing routine activities for short periods of time and work full-time, 5 days a week.
Ultimately, the court ruled for Mr. Cohen and awarded him past-due benefits and an award of attorneys’ fees.
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