Court Rules Aetna Erred in Denying Long term Disability Benefits
In Charles v. UPS National Long Term Disability Plan et al., the plaintiff, Marvin Charles, was being treated for a reoccurrence of a seizure disorder, a condition that had been dormant for about 30 years. In 2008, he had a grand mal seizure and consulted with his physician who prescribed Lacmital, a medication used for the control of seizures. He was granted 24 months of short term disability when Aetna agreed he was unable to perform the duties of his own occupation.
Aetna Denied Long Term Disability Benefits When There was no Objective Proof Plaintiff Suffered From Fatigue
After 24 months, plaintiff applied for long term disability. At this time, the definition of disability changed and now Charles was required to prove he was disabled from performing the duties of any reasonable occupation. His treating physician reported that Charles was disabled from performing the duties of any occupation due to the fatigue he suffered from as a side effect of Lacmital. The Lacmital could not be discontinued because it kept his seizure disorder under control.
Aetna denied Charles long term disability benefits on the grounds that there was no objective proof Charles suffered from fatigue. In its decision finding Aetna abused its discretion in denying Charles long term disability benefits, the Pennsylvania District Court relied on Third Circuit precedent and held, “Aetna’s expectation that the plaintiff should undergo some additional ‘clinical’ test to prove that he is, in fact, experiencing fatigue from his medication is arbitrary and capricious.”
Court Ruled Against Aetna Holding That it Abused its Discretion in Requiring Objective Proof of a Medical Condition When no Objective Proof Exists
Plaintiff’s treating primary care physician repeatedly reported that Charles suffered from fatigue, as a side effect from Lacmital, to a degree that he could not be employed full time at any reasonable occupation. Aetna seemed to ignore those reports and relied instead on its independent reviewers of plaintiff’s medical records who claimed there was no clinical or objective evidence to support the restrictions placed on the plaintiff’s ability to work.
The federal district court noted it was “not clear what type of clinical evidence Aetna thought was missing” and went on to recount the evidence supporting the plaintiff’s complaints of fatigue:
- The Food and Drug Administration has listed side effects of the medication which include tiredness, insomnia, and sleepiness as well as others that cause a person to be fatigued.
- The plaintiff’s self-reporting of fatigue.
- Plaintiff’s primary care physician and neurologist both found that his fatigue was due to a side effect of the medication.
- The two treating physicians were monitoring his treatment and both believed Charles needed to continue taking Lacmital despite his fatigue because it kept his seizures under control.
The court ordered Aetna to pay long term disability benefits, finding that for Aetna to expect more documentation “under these circumstances is an abuse of discretion.” The court relied on a 1997 case that held it was arbitrary and capricious for an insurer to require clinical evidence for “a condition with no ‘dip-stick’ lab test.”
This case was not handled by our office, but it may provide claimants guidance in their pursuit of long term disability when they suffer from a condition, such as fatigue, for which there is no “dip-stick” lab test that exists that can provide objective evidence of the condition. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.
Resources to Help You Win Disability Benefits
Submit a Strong Appeal Package
We work with you, your doctors, and other experts to submit a very strong appeal.
Sue Your Disability Insurance Company
We have filed thousands of disability denial lawsuits in federal Courts nationwide.
Get Your Disability Application Approved
Prevent a Disability Benefit Denial
Negotiate a Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Policy Holder Rating
Aetna STD has been a nightmare since the beginning
Reply
Aetna leaves me at risk of losing my job and without compension
Aetna puts their clients through hell with their games
Reply
It's been over 3 months, and I've only received one payment from Aetna
Reply
Aetna people are thieves, crooks and liars.
Aetna is definitely committing a crime and they need to be stopped.
Reply
I hate Aetna
Reply
Aetna denied me and then I got fired from my job
Reply
Q: Can Aetna deny my application on the basis of pre-exisiting condition? Do they discriminate against the mentally ill?
Q: Are there any circumstances in which I can appeal LTD after the number of days Aetna gives you to appeal?
Q: Can Aetna deny my claim due to a "war exclusion" on my policy?
Q: What do I do if Aetna claims they haven't received my medical info?
Q: How can Aetna say I am not disabled when clearly I am?
Q: Is the 2nd appeal process worth it or a waste of my time?
Q: What can I do to stop Aetna from harassing me and realize that not all disabilities are the same?
Q: Can Aetna deny my claim for STD due to pregnancy because it was preexisting?
Does Social Security Approval Mean Disability Insurance Benefits Will Be Paid?
Does a disability insurance company need to consider the side effects of my medications?
Does the Mental Nervous Disorder Limitation in an ERISA Long Term Disability Plan Violate ADA Laws?
Is it legal to limit disability insurance benefits to 24 months for mental nervous claims?
Why Must Your Disability Insurance Lawyer Understand Your Disabling Condition?
Disability Benefit Denial Reason #5 – Your Medical Evidence is Weak
Disability Benefit Denial Reason #4 - Your Doctor Is Misled By the Disability Company
Disability Benefit Denial Reason #3 - Video & Social Media Surveillance
Aetna Overturns Denial of Long Term Disability Benefits for Quality Control Manager
Aetna Removes 24 Month Limitation for Mental Health Conditions
Aetna Overturns Denial of LTD for Former Employee of The Home Depot
Aetna Reinstates Benefits for Former SAP America Employee Suffering the Effects of a Head Injury
Aetna overturned previous denial of long term disability benefits for Georgia Assistant
Dell Disability Lawyers file Lawsuit in Federal Court against Aetna after it denied long-term disability benefits to former software Developer
After Aetna denied Ms. Garner's long-term disability claim, Ms. Garner filed suit against Aetna, and the Court overturned Aetna's decision and ordered it to pay Ms. Garner's disability benefits
Aetna Reinstates Disability Insurance Benefits to Home Depot Manager
Reviews from Our Clients






