Disability Benefits Obtained in Long-Term Disability Claim

BenGlassLaw Long-Term Disability Team Obtains $500,000 in Benefits After Aetna Failed to Give Treating Doctors Time to Review Functional Capacity Report

Our client worked in a sedentary occupation and had been paid benefits by Aetna life insurance company for just over two years. In October, Aetna terminated the benefits based largely on the results of a functional capacity exam (FCE). Once benefits were terminated the client had 180 days to appeal the denial. She retained us.

The Functional Capacity Exam (FCE)

A Functional Capacity Exam (FCE) is a comprehensive evaluation used to measure an individual’s physical abilities and limitations, particularly in the context of their ability to perform work-related tasks. This exam is often a critical component of long-term disability claims, as it provides objective data about a claimant’s physical capabilities, helping to determine the extent of their disability and their potential to perform their job or any job for which they are qualified.

The FCE typically consists of a series of tests conducted over several hours or even a couple of days. These tests are designed to assess various physical functions including strength, flexibility, endurance, and range of motion. The exam might also evaluate the claimant’s ability to perform specific job-related tasks such as lifting, carrying, pushing, and pulling. Additionally, the FCE can assess situational abilities such as sitting, standing, walking, and climbing stairs, which are relevant to many work environments.

Administered by a licensed physical therapist or a professional trained in physical and occupational therapy, the FCE not only measures the physical aspects but also looks at pain response, effort, and consistency of performance throughout the evaluation. This comprehensive approach helps to ensure that the results reflect a true measure of the claimant’s functional abilities and limitations.

The findings from an FCE are compiled into a detailed report that provides insight into the level of work an individual can perform safely without risking further injury. This report can be used by disability insurance providers to make informed decisions about the claimant’s eligibility for benefits. It can also assist employers in understanding accommodations that may be needed to support the employee’s return to work, ensuring that they are placed in an appropriate role that matches their functional capacity.

We Got the Claim File and Found the Gold

Once we obtained Aetna’s entire claim file we discovered that after it had obtained the FCE it had hurriedly asked the client’s treating physicians to comment. When we traced back the dates that letters were actually mailed and received (as opposed to when the insurance company said letters were mailed and received) he discovered that Aetna had given the treating physicians very little time to respond before issuing its final denial letter.

Aetna had also advised our client that she must apply for Social Security disability benefits. Even though those benefits were approved (paying her $2500 per month) Aetna said, in essence, “we are not bound by the Social Security Administration decision.” Aetna however required that our client pay it back a huge sum of money based upon her receipt of “double benefits.” (This is a normal process in group long-term disability claims.)

In the context of group long-term disability (LTD) insurance policies, “other income” provisions are crucial elements that impact the benefits a claimant receives. This often includes Social Security Disability Insurance (SSDI) benefits, and understanding these provisions is key for claimants managing their financial expectations and obligations.

Understanding “Other Income” Provisions

Group LTD policies typically include “other income” or “offset” provisions, which specify that the amount paid out by the insurance company may be reduced by income the claimant receives from other sources. These sources can include Social Security disability benefits, workers’ compensation, pensions, or certain other government or private disability payments. The rationale behind these provisions is to prevent the claimant from receiving more in benefits than they earned when they were working, aiming to replace only a portion of lost income and thereby encouraging return to work if possible.

Social Security Disability Awards

When a claimant receives a Social Security disability award, this can directly impact their LTD benefits. Social Security benefits are often considered as “other income” under the terms of most group LTD policies. Therefore, if a claimant starts receiving SSDI benefits, the amount they receive from their LTD insurance may be reduced accordingly. This is commonly referred to as an “offset.”

Reimbursement to LTD Insurers

The reason claimants must reimburse their LTD insurance company after receiving a Social Security disability award stems from these offset provisions. When a claimant applies for LTD benefits, the insurer often estimates potential SSDI benefits and pays what it owes minus this estimated SSDI amount. If the claimant later receives a retroactive SSDI award (back pay covering the period during which the LTD benefits were also received), there arises an overlap where the claimant has effectively received more than their policy stipulates due to the insurer’s initial overpayment.

To rectify this, the claimant is required to reimburse the insurance company for the overpaid amount, aligning the total benefits received with the policy’s terms. This reimbursement ensures the balance of payments remains within the defined limits of income replacement as per the insurance contract and prevents the financial over-burdening of the insurance system.

Importance for Claimants

For claimants, it is crucial to understand these provisions and their implications for financial planning. Awareness of how SSDI awards interact with LTD benefits can help manage expectations and budgeting. Additionally, claimants should be prepared for potential reimbursements they may owe to their LTD insurer, which could significantly impact their overall financial resources during their period of disability.

Overall, these policies and provisions are designed to maintain fairness and sustainability within the insurance system, ensuring that benefits serve their purpose without providing undue excess.

How BenGlassLaw Beat the Insurance Doctor Opinions on the Functional Capacity Exam

When we examined what actually occurred during the functional capacity exam and contrasted it with Aetna’s conclusion about what happened we were able to point out dramatic differences. We researched the physical therapist who had conducted the functional capacity exam for Aetna and pointed out that he was literally brand-new to the profession having only been in business for three years.

We pointed out that previous experts that Aetna had hired had all agreed that our client was disabled. We argued that there was no material change in her condition which should have caused Aetna to terminate her benefits. We did an in-depth study of her entire record.

We then obtained additional new medical information and comments from others who had been able to witness the level of activity that our client was capable of engaging in. We also prepared a detailed study of the medications are client had to take because of her chronic pain and their effect on her capacity to be employed.

Finally, we pointed out that Aetna cannot arbitrarily ignore the comments and conclusions of the treating physicians.

Because of the reversal of Aetna’s termination of benefits our client will receive approximately $500,000, payable monthly, to age 65.

Ben Glass Leads the Long-Term Disability Section at BenGlassLaw

Disability Benefits Paid by Aetna in Long-Term Disability Claim

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