Our client worked in a sedentary occupation and had been paid benefits by Aetna life insurance company for just over two years. In October, 2013 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.
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.)
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.
