Aetna Life Insurance Company has attracted significant judicial scorn of late in the manner in which it adjudicates disability benefits.Two recent decisions are illustrative – Jalowiec v. Aetna Life Ins. Co., 2015 WL 9294269 (D. Minn. December 21, 2015) and Granville v. Aetna Life Ins. Co., 2015 WL 9026025 (M.D. Pa. December 15, 2015). In Jalowiec, which involved a disability insurance claimant who suffered from daily debilitating headaches, a benefit claimant was denied long-term disability insurance benefits despite certification of his disability by several treating doctors.The court criticized Aetna for its reliance on reviewing doctors who engaged in a selective consideration of the evidence and who never consulted with the treating doctors to seek clarification of their opinions.

Granville involved a claimant who suffered from stenosis of her cervical spine with radiculopathy. The court itemized several indicia of arbitrariness committed by Aetna in its claim review:

(1) reversing a decision to award benefits without new medical evidence to support the change in position, (2) relying on the opinions of non-treating over treating physicians without reason, (3) conducting self-serving paper reviews of medical files, (4) failing to address all relevant diagnoses before terminating benefits, (5) relying on favorable parts while discarding unfavorable parts in a medical report, and (6) denying benefits based on inadequate information and lax investigatory procedures.

In addition to performing an inadequate file review and failing to obtain a physical examination of the claimant, the court was especially critical of Aetna’s failure to assess the claimant’s actual job duties – “Finding her capable of sedentary work and not completely disabled does not speak to [the obligation to assess disability in relation to the claimant’s occupation] even where Plaintiff’s own occupation was classified as a sedentary demand level.”

The court also deemed Aetna’s correspondence “borderline unconscionable” because of the tiny fonts it utilized.

Jalowiec is also notable for its finding that “[a]n insurer is ‘not free to accept [an independent reviewer’s] report without considering whether its conclusions follow logically from the underlying medical evidence.'” The court added that an insurer may not lawfully rely on “an independent reviewer’s report that reflects an ‘incomplete, selective review of the medical evidence.'” Id. at 702.  The court also deemed it improper to deny benefits “simply because a claimant cannot provide a diagnosis that would explain her self-reported symptoms.” (citing Collins v. Cont’l Cas. Co., 87 F. App’x 605, 606 (8th Cir. 2004)).

These two decisions are among several rulings issued over the past few months that have expressed harsh criticism of Aetna’s claims handling practices.  Both rulings, as well as the other cases that have found against Aetna, have focused on Aetna’s practice of utilizing file-review consultants who overlook critical evidence and on inadequate vocational assessments.  Aetna has drawn particular scorn for its dismissal of pain complaints as “self-reported” despite objective corroboration of the claimants’ symptoms.

Related Articles

ERISA Ruling Reinforces Claimant Right To Know Denial Basis

ERISA Ruling Reinforces Claimant Right To Know Denial Basis

One of the unique aspects of litigation under the Employee Retirement Income Security Act is that most courts limit the scope of their review to the claim record compiled during the course of the claim and prelitigation appeals and will not address new evidence that was not previously considered. […]

Congress Must Ban Discretionary Clauses In ERISA Plans

Congress Must Ban Discretionary Clauses In ERISA Plans

A recent Law360 guest article argued that discretionary clauses in employee benefit plans governed by the Employee Retirement Income Security Act serve a valuable function, and that if efforts to prohibit their inclusion are successful, the statute would be undermined […]