The following summary of one woman's experience with her insurer in a long-term disability matter almost reads like a bad novel.
Unfortunately, though, and as a proven claimants' rights attorney can readily attest, the fact pattern is anything but rare. Moreover, it underscores how vital it can be for a disabled individual to secure help from seasoned legal counsel to obtain a just result in a disability case.
In a nutshell, the woman was continually rebuffed by Aetna (please see our February 15 blog post for a chronicling of that insurer's recent woes linked with its LTD policies) when applying for LTD benefits. In the claim's early stages, Aetna did not even have a doctor examine the claimant's file. Rather, it left its decision in a nurse's hands, who denied the claim.
Then in rather telling fashion, after the receipt of additional medical records supporting disability, the claim was referred straight back to the same nurse who unsurprisingly denied it again.
In its next stage, a company-recommended doctor denied the claim for a third time. That resulted in the woman filing a lawsuit against Aetna, charging the company with "arbitrary and capricious" behavior.
A federal judge recently endorsed that view, calling Aetna's denial "unreasonable" and the doctor's conclusion unacceptable "because it completely lacked evidentiary support." Case evidence indicated that Aetna's retained physician relied upon another doctor's denial conclusions without sufficiently examining them. Moreover, he did not seem to consider the findings of the woman's doctor at all.
Owing to those deficiencies, the federal judge overseeing the case returned it to Aetna for reconsideration.
Sadly, experienced claimants' advocates hear of such cases routinely and know that the results will often markedly differ when the help of established legal counsel is timely solicited.
As we note in the above-cited blog entry, when an insurer fails to act in good faith in a disability matter, "a proven legal team can advocate aggressively for [a claimant] and seek maximum compensation on a claim."