Legal Summary: Webber v. Aetna Life Insurance Company

Webber v. Aetna Life Insurance Company
375 F. Supp. 2d 663 (E.D. Tenn. 2005)

Our client worked as a sales agent for Cendant.  Prior to his employment, he was diagnosed with a chronic medical condition and received treatments for this condition since at least February 2000.

In 2001 our client suffered an acute asthma attack and applied for short term disability (“STD”).  His treating physician stated that he could not return to work at this point due to his fatigue, decreased endurance and concentration.  That same treating doctor submitted an second attending physician statement (“APS”) further describing our client’s condition, explaining his medical conditions in detail.

Our client’s treating doctor also opined that our client could not perform any tasks that need stamina, concentration, prolonged sitting or standing and concluded that the plaintiff could not work.  In November 2001 our client was also diagnosed with avascular necrosis (“AVN”) in his hips, which is the death of bone tissue due to a lack of blood supply that can lead to breaks in the bone and the eventual bone collapse.  The plaintiff reported that his hip problem inhibited his movement and tired him out because it took so much effort to walk and avoid hip pain.  His doctor stated he was unable to work due to severe physical limitations.

Aetna reviewed his claim for LTD and denied it, pointing to a pre-existing condition exclusion, claiming our client’s AVN was related to his prior medical condition.  Our client requested a review of this decision.  Our client agreed he had a prior chronic medical condition, but disagreed that his AVN was related to a prior medical condition. His doctor agreed.

Aetna’s doctors reviewed the file and disagreed with our client’s doctor; instead, they asserted our client’s AVN was related to his prior medical condition, therefore it was preexisting. Based on their own doctors’ opinions, Aetna denied LTD again.

After this denial our client had total hip replacement of both hips; however, Aetna’s doctor concluded that he could still perform sedentary (his own occupations) activities.  She also stated that there was no evidence that his AVN was pre-existing or related to his chronic condition.  Aetna denied LTD again based on her opinion that the plaintiff was not totally disabled from performing his own occupation.

After Aetna issued that denial, we filed a lawsuit against Aetna on behalf of our client.

In court we argued that Aetna’s decision to deny benefits was arbitrary and capricious.  The court determined that there were three issues in this case:  (1) whether Aetna’s application of the Active Work Rule to exclude plaintiff from being covered was arbitrary and capricious; (2) whether Aetna’s determination that the plaintiff’s AVN was pre-existing was arbitrary and capricious; and (3) whether Aetna’s determination that the plaintiff’s AVN was not disabling was arbitrary and capricious.

We argued that Aetna’s denial of his LTD benefits based on the Active Work Rule was arbitrary and capricious.  The plan contained an Active Work Rule, which stated that coverage for illness or injury would not take effect until the employee return to full-time work.  Our client left work due to asthma but then developed AVN.  Aetna argued that since the plaintiff left work because of asthma and then developed AVN without returning to work, plaintiff was excluded from coverage under the Active Work Rule.  The court concluded that the Active Work Rule spoke in terms of coverage under the plan, not in terms of coverage for a particular disability.  Thus, since our client was eligible for benefits when he first became disabled, the court concluded that it was not reasonable to use the Active Work Rule to deny his coverage for AVN.

Second, we argued that Aetna’s denial based on treating his AVN as a pre-existing condition was also arbitrary and capricious.  Only one physician ever noted that his AVN could be related to his chronic medical condition.   Four other medical opinions in the record concluded the opposite, that his AVN was not a preexisting condition.  The opinions of two of the plaintiff’s doctors both stated that the AVN was not related to our client’s chronic medical condition.  Two of Aetna’s file-reviewing doctors came to the same conclusion that the plaintiff’s AVN was not caused by a preexisting condition.

Despite these four opinions, Aetna chose to rely on one file reviewer who concluded that plaintiff’s AVN was a pre-existing condition.  The court explained Aetna is not required to give special deference to the plaintiff’s treating physician; however, Aetna may not arbitrarily rely on one of its own consultants in the face of all other contrary evidence.  See Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 362 (6^th Cir. 2002)(insurance company acted arbitrarily in relying on one report from physician instead of entire file); Williams v. International Paper Co., 227 F.3d 706, 713 (6^th Cir. 200)(administrators decision not to consider all of the medical evidence was arbitrary and capricious).  Thus, the court concluded that Aetna’s conclusion that plaintiff’s AVN was preexisting was nor reasonable based on all the evidence.

Finally, one of Aetna’s doctors concluded that the plaintiff would not necessarily be impaired from sedentary duties due to his AVN.  Aetna based its denial on this one doctor’s opinion.  However, several other doctors, including our client’s treating doctor and two of Aetna’s file-reviewers, all agreed that plaintiff would not be able to work as a result of his AVN.  In fact, the record was full of evidence from these three that the plaintiff suffered from significant pain and physical limitations.  His condition was so severe that the plaintiff had to undergo two hip surgeries and rehabilitation.  In light of the evidence provided in the record regarding his pain, physical limitations, surgery and rehabilitation, the court found it hard to understand why Aetna would accept one doctor’s opinion over all this contrary evidence.  Thus, the court found Aetna’s conclusion that the plaintiff’s AVN was not disabling was arbitrary and capricious.