Aetna is a managed health care company that provides health care insurance and related services to its customers, including long term disability plans. They’re one of the biggest long term disability insurance providers in the United States. Marc Whitehead & Associates have represented many clients who have had their valid claims for long term disability benefits denied by AETNA. In many cases we have helped our clients prepare and file an appeal that successfully secures the benefits they deserve. In other instances, when the appeals process is exhausted and yielded no results, we have had no choice but to file a lawsuit in Federal Court to protect our clients’ rights.
Marc Whitehead & Associates recently represented a 48-year-old woman, from Savannah, Georgia, during her appeal of an Aetna Life Insurance Company’s denial for long-term disability (LTD) benefits.
Our client suffered from thoracic lumbar radiculopathy, fractured ribs, sleep apnea, depression and anxiety. Some of her symptoms included severe chronic pain, which she managed with the help nerve blocks, physical therapy, and prescription medications; the inability to sit for prolonged periods of time and problems concentrating. The difficulties she has experienced coping with her painful symptoms often left her with feelings of depression.
Her physician’s prognosis: our client’s condition was such that she was unable, and would continue to be unable, to perform the duties of any occupation, even a sedentary job.
Aetna’s Decision
Aetna disagreed. They denied our client’s claim for disability benefits. Their opinion, even after reviewing the medical documentation regarding her pain, restrictions and limitations and her ongoing treatment, was that our client was still able to work in a sedentary capacity.
The Social Security Administration describes sedentary work as an occupation that “involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools.” They go on to state, “Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.”
These occupations require a certain level of productivity and this is just not something our client can do. They also do not allow for the taking of unscheduled work breaks due to frequent and severe pain as our client was forced to do.
In arriving at their decision, Aetna failed to fully address the effects of her pain and the side effects of her medication.
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Appeal of Aetna LTD Denial Filed by Marc Whitehead & Associates
In writing their opinion, the Aetna disability claim analyst who denied the claim provided no explanation as to why they doubted the accuracy of our client’s medical complaints and the opinions of her treating physicians.
We felt that Aetna had based their opinion an unreasonable interpretation of a Functional Capacity Evaluation and an unreasonable vocational assessment to deny our client’s claim for disability benefits. We were determined to prove that Aetna was not justified in rejecting the opinions of treating physicians as well as our client’s statements.
Marc Whitehead & Associates prepared an appeal of Aetna’s decision, demonstrating that Aetna erred when they disregarded the evidence supporting our client’s claim that her impairments, including the multiple right sided rib fractures that produced unmanageable pain after only minimal stress or movement, render her incapable of performing the duties of even sedentary work. By researching every medical document, requesting additional testing and physician statements, and carefully reviewing each statement made by the disability insurance company, our attorneys were able to create a solid argument against AETNA’s denial of our client’s LTD claim.
Importance of a Physician’ Opinions in Reversing Aetna LTD Denial
Many courts have found that non-exertional, or pain, limitations, confirmed by the professional opinion of a treating physician, can trump what would otherwise be a capacity to engage in sedentary work. Our experience has shown us that ignoring pain limitations may be an indication of uncertainty on the part of the insurance plan administrator.
During our appeal, we were able to show that Aetna had failed to take into consideration how our client’s severe chronic pain affected her ability to work. There was a great deal of well documented medical testing which indicated an objective reason for our client’s pain. We introduced evidence which went into great detail explaining our client’s inability to perform the duties of any of the sedentary jobs that Aetna had suggested. This included records — written opinions from her treating physicians — stating that our client’s impairments prevent her from performing any work at all at the present time, which served to contradict Aetna’s determination.
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How a Social Security Disability Decision Aided in Reversing of Aetna LTD’s Denial
Before our client’s Aetna Long Term Disability insurance benefits claim was denied, the Social Security Administration had ruled that our client is disabled from any occupation at any level and granted her disability benefits. However, Aetna persisted in denying our client’s LTD benefits by asserting that she was able to perform the duties of a sedentary occupation.
Although AETNA claimed it did not have the same medical information as the Social Security Administration, we demonstrated that was not true. The disability insurance company had provided representation for our client through Allsup (a 3rd party company that specializes in assisting those with social security disability claims) and constantly monitored our client’s progress and SSA disability benefits award. Aetna could have easily gotten access to our client’s SSA file.
In addition, we were fortunate to have the case reviewed by a dedicated Aetna senior appeal specialist who thoroughly examined each document we sent. After reviewing the documents, the appeals specialist came back with a decision to overturn the previous Aetna disability claim analysts’ decision and approve LTD benefits for our client.
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Attorneys for Aetna Disability Claims
Don’t make the mistake of trying to appeal a denial of disability benefits on your own. Marc Whitehead & Associates have helped thousands of disabled workers and military personnel get the disability benefits they deserve. There are many factors that determine whether your appeal is rejected or not and we know them all. Don’t risk losing out on benefits — contact Marc Whitehead & Associates to speak with a Aetna disability claims attorney about your claim. If you need help today, call us at 800-562-9830 for a free case evaluation.
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