A recent ruling issued by a federal court in Philadelphia illustrated a number of issues relevant to disability insurance claims brought under ERISA. In Charles v. UPS Long Term Disability Plan, 2015 WL 6600399 (E.D. Pa. October 29, 2015), after first finding the plaintiff was limited to part time work and thus unable to work at an occupation that would generate an income equal to 60% or more of pre-disability earnings, Aetna shifted gears and denied benefits. The claimant had been a delivery driver for UPS who became disabled on account of a seizure disorder and could no longer qualify for a commercial driver’s license based on the condition and the prescribed anti-convulsant medications which cause sedation and fatigue.  The plan’s insurer, Aetna, had the file reviewed by doctors and vocational consultants who issued findings that Charles could work full time and that there were occupations he could perform that would generate the requisite wages. The court overturned that finding in a harsh ruling that included the quotation that is the title of this blog.

The court was disturbed by Aetna’s insistence on “objective medical evidence” in the absence of a policy requirement mandating such evidence. Moreover, the court found that the nature of Charles’ impairment made it impossible for him to produce the type of evidence that Aetna demanded.  The court was also dubious about the validity of Aetna’s vocational assessment and also questioned its medical consultants’ findings.

In sum, the court found:

Overall, Aetna’s determination appears to have given great weight to their own experts while giving little, if any, consideration to the plaintiff’s own treating physicians.  Without further explanation, this is an abuse of discretion. See Ricca v. Prudential Ins. Co. of Am., 747 F.Supp.2d 438, 445-46 (E.D. Pa. 2010)(“Given the conflicting evidence in the record, Prudential’s decision to accept the opinions and conclusions of its experts without explanation is itself arbitrary and capricious. The evidence of plaintiff’s subjective complaints of pain and physical limitations must be considered along with evidence that her complaints are groundless.”)

Although the court agreed with Aetna that it was not obligated to defer to the treating doctors, it pointed out that Aetna did not have a license to ignore reliable evidence, yet it appeared to the court that Aetna did just that.

The court covered a lot of ground in rejecting Aetna’s refusal to consider subjective complaints, Aetna’s disregard of medication side effects, Aetna’s selective review of the evidence, and its over-reliance on reviewing doctors. It was thus not at all surprising that the court concluded that Aetna appeared to have been acting under an improper motive that was contrary to its fiduciary obligations imposed by ERISA.

Related Articles

ERISA Ruling Reveals Big-Picture Health Benefit Issues

ERISA Ruling Reveals Big-Picture Health Benefit Issues

Unlike most industrialized countries, the U.S. does not provide universal government-sponsored health insurance coverage to all of its citizens and residents. Instead, most Americans receive coverage through their employer, while older Americans and people of lesser means receive either Medicare or Medicaid benefits. […]

7th Circuit Holds ERISA Does Not Cover Charter School Teachers

7th Circuit Holds ERISA Does Not Cover Charter School Teachers

The Employee Retirement Income Security Act impacts hundreds of millions of Americans who participate in employee benefit plans sponsored by their employers. However, as Graham v. Board of Ed. Of City of Chicago, 2021 WL 3508563 (7th Cir. Aug. 10, 2021), recently pointed out, ERISA doesn’t cover all employer-sponsored plans […]