Denial of Long-Term Disability Benefits: Aetna® Hoisted on Its Own Petard

Many hardworking people have the foresight to purchase long-term disability (“LTD”) coverage to ensure their ability to provide for the financial needs of their family in the event of injury or illness.  The basic function of LTD coverage is to supplement or replace the income of a family breadwinner in the event of physical or mental incapacity that adversely impacts a family or individual’s monthly household income.  However, this form of financial security can suddenly be placed in peril because an insurance company delays, denies, or discontinues LTD benefits.  Although some disabled policyholders assume that their prospects of prevailing against a denial or termination of benefits are poor, an experienced Miami insurance claims attorney can analyze the terms of a policy and represent your interests in fighting for LTD benefits.

A recent federal court case from the First Circuit of the U.S. Court of Appeals, McDonough v. Aetna Life Insurance Co., provides an example of how a knowledgeable insurance attorney can make a difference in holding an insurance company to the standards set forth in its own policy.  The insured filed a claim under an employer-provided LTD plan after leaving his job because of stroke-like symptoms.

Under the language of the LTD plan, an insured would be considered disabled if he was “not able to perform the material duties of [his] own occupation solely because of disease or injury; and [his] work earnings are 80% or less of [his] adjusted predisability earnings.”  The policy further defined “material duties” as those “normally required for the performance of [his] own occupation . . . .”  The duties were evaluated under the policy by considering the relevant occupation in the context of the entire industry across the U.S. rather than the duties performed with the specific employer.

While the insurer initially provided LTD benefits, Aetna® terminated the payments after a few months.  The insured worked as a senior systems analyst who functioned as both a supervisor of systems and employees.  The insurance company claimed that the policyholder was no longer disabled because he could handle sedentary work on a forty hour per week basis.  The insured submitted medical records revealing that he continued to experience weakness and numbness that limited his ability to type and write.  The policyholder also submitted evidence indicating he was suffering from mental impairments and conditions, including insomnia, anxiety and panic attacks that collectively impaired his ability to continue in a high stress job with long hours.  These stress-based conditions also prevented him from handling the 24/7 on-call duties of his position.

While the district court decided the case in favor of the insurer, the appellate court reversed.  This is where good lawyering becomes important because the insured’s attorney used the insurance carrier’s “own occupation” standard against the company.  The appellate court pointed out that the insurer failed to account for the mental demands of the policyholder’s “own occupation” as performed by those in a similar position within the national economy.  The insurance company did not even purport to consider the policyholder’s limitations and conditions in the context of the physical and mental rigors of his “own occupation” as set forth by the policy.  The insurer also failed to analyze the demands of the occupation based on industry norms.  Because of the failure of the insurer to consider the cognitive demands, extreme stress, and physical tasks involved in the occupation on a national basis, the appellate court found the insurance company’s decision was arbitrary and capricious.

While the prospect of taking on an insurer that refuses to pay LTD benefits can seem daunting, an experienced Florida insurance claims lawyer might well be able to hoist the insurer on its own petard.  However, insurance policy language is voluminous, complex and difficult to parse, so you should seek legal advice.  If your insurance company is using sharp practices or otherwise fails to process and pay your long-term disability claim in a timely manner, you might have a legal claim for financial compensation.  My law firm represents policyholders in claims disputes in Miami and throughout Florida. The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations. No Recovery, No Lawyer Fees. Call us now at 305-461-1095, or Toll Free 1-866-71-CLAIM. 

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