Legal Summary: Satter v. Aetna Life Insurance Company

Satter v. Aetna Life Insurance Company
No. 3:16-CV-1342(AWT), 2019 WL 2896410 (D. Conn. 2019)

Our client was employed by a financial services company as a financial planner until she became disabled due to fibromyalgia and memory loss, for which she applied for short and long-term disability benefits from Aetna Life Insurance Company (“Aetna”).

In order to be considered disabled under Aetna’s plan, (1) you must be unable to perform the material duties of your own occupation (defined as the occupation one is “routinely performing when the period of disability begins” and views the occupation as it is performed in the national economy instead of how it is performed for a specific employer or work site) solely because of an illness, injury or disabling pregnancy related condition; and (2) your earnings must be 80% or less of your adjusted pre-disability earnings.

Under Aetna’s plan, an individual will “no longer be considered as disabled nor eligible for long term monthly benefits” when he or she no longer meets the long term test of disability or fails to provide proof of meeting said test.

Aetna denied our client’s claim for long-term disability benefits, stating that its decision was based on a review of the information received, including medical records; the results of a clinical consultant review; and an independent peer review of three medical consultants.

We sued Aetna for wrongfully denying our client’s claim.  Among our other arguments, we argued that Aetna violated the U.S. Department of Labor ERISA claims regulations found at 29 C.F.R. § 2560.503-1.  Specifically, the regulations require an insurance company to make a decision within 45 days, that can be extended if “special circumstances” require an extension of time, which can be for another 45 days.  We argued that Aetna’s attempt to take a 45-day extension did not satisfy the requirements of special circumstances under the ERISA claims regulations.  The court agreed.

Specifically, Aetna informed our client of its request for a 45-day extension only 5 days before the 45 days lapsed; the stated reason was for the insurance company to obtain an “independent medical review.” The court explained that, under the ERISA claims regulations, insurance companies are required to consult with appropriate health care professionals, and that, since that is a requirement, it is normal part of the ERISA appeals process; calling that a “special circumstance” would mean virtually any extension request would be permissible.

Further, on the date of the notice of the request for the extension, Aetna had not even appointed a doctor to conduct the review; rather, Aetna “merely anticipated appointing one.” Satter v. Aetna, 2019 WL 2896410, 6 (D. Conn March 20, 2019).  The court noted that Aetna had earlier tried to appoint a reviewing doctor, but when that failed, Aetna waited 30 days to try to appoint another one. The court concluded, “failure to appoint a reviewing doctor in a timely manner is not a ‘special circumstance’ under 29 C.F.R. § 2560.503-1(i)(1)(ii).” Satter, at 6.  Further, this was not an extension request for something beyond the control of the administrator, but was within the control of the insurance company.

Because Aetna failed to comply with the claims procedure regulations, the court applied the de novo standard of review, applying the rule in the Second Circuit under Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016).

Under the de novo standard of review, the plaintiff bears the burden of proving that they qualified for the benefits sought. The court evaluated whether our client provided sufficient evidence to support her claim that her fibromyalgia and memory deficiencies rendered her incapable of working at her own occupation as it is performed in the national economy. The court ruled that our client had established such physical and cognitive restrictions by a preponderance of the evidence, proving that she is entitled to benefits under the plan.

Despite Aetna claiming otherwise, the court determined that our client’s medical records contained substantial evidence of her physical and cognitive impairments. Aetna also argued that there was no objective evidence of our client’s claimed impairments. However, multiple doctors, tests, and reports indicated that our client was suffering from physical and cognitive impairments, stemming from her fibromyalgia and the medication she was taking.

Our client’s primary care doctor completed an attending physician’s statement (in support of a Family Medical Leave Policy Medical Certification Form), in which he stated that she was unable to perform her job due to chronic pain and disability, depression and anxiety, medication side effects compounding mental fogginess, impairing memory, logic and decision-making. Another physician explained how the areas where our client performed worst in a cognitive test was important in terms of her not being able to meet the demands of her former occupation. Neither Aetna nor its consulting neuropsychologist addressed this concern in Aetna’s denial.

Aetna also hired a rheumatologist, who was only able to conclude from our client’s file that “there is insufficient evidence to support functional impairment … from a rheumatology standpoint.” The court found his opinion to be entitled to little weight in evaluating the opinions of our client’s neurologist and a neuropsychologist.

We also submitted the analysis of a vocational expert (“VE”) who considered the restrictions placed on our client by the physicians who examined and treated her; the VE concluded that our client’s cognitive impairments rendered her unable to perform her own occupation as performed in the national economy. Reports from the same doctors who treated her for multiple years established that she is unable to perform the duties of a financial planner.

The court rejected Aetna’s arguments that the evidence did not support our client’s disability, such as, “her ability to remain at her occupation nine months after she first claim[ed] she wanted to start disability leave.” Satter at 9. The court explained that, instead, our client’s “actions during the period in question were those of someone who was making every effort to work and avoid taking a disability leave.” Id.

Aetna also argued that the court should not rely on the opinions of our client’s doctors because the statements and findings of their examinations and restrictions and limitations were “inconsistent.”  The court rejected Aetna’s argument on this point as well, explaining the inconsistencies were “not material.” Id. Specifically, all of the restrictions assessed would result in our client being disabled; they just varied some on the severity of the restrictions.

The court also rejected Aetna’ assertion that our client’s medical records did not sufficiently support her disability, in part because her doctors has said she “did not appear in any acute distress” during her appointments. Id.  The court explained that someone can still be disabled, and can be in pain and be unstable, because not being in “acute distress … simply indicates that the patient is not in need of immediate emergency attention,” citing a medical article on that issue. Id.

Lastly, Aetna argued that our client’s diagnosis of fibromyalgia did not provide “objective evidence of [her] claimed impairments.” Id, at 10.  The court rejected this argument citing to The Merck Manual, 269 (20th ed 2018), which explains that fibromyalgia is diagnosed using clinical criteria and testing and physical examinations to exclude other disorders, and that the diagnosis is based on the clinical criteria for fibromyalgia from the American College of Rheumatology. The court then went on to explain how the medical records supported those diagnostic criteria.

After rejecting the arguments from Aetna, the court further examined the medical evidence and the opinions of our client’s examining and treating doctors. The court ultimately ruled that our client had proved, by a preponderance of the evidence, that she is entitled to benefits under Aetna’s plan.

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