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Did Your Doctor Really Say That to The Disability Insurance Company?

Posted by David P. Martin | Jan 20, 2017 | 0 Comments

Donna Kendrick had a great job working for Gulfstream Aerospace. She thought she was set for her working life, as she had good benefits with her company and enjoyed her work. One of those benefits was a long term disability policy insured by Aetna.

Ms. Kendrick's health took a turn for the worse in 2013, involving Type 2 Diabetes. She had fatigue, dizziness, confusion, short term memory loss and migraines. She also developed gastrointestinal distress, rash, joint pain and sleep problems. Finally, she filed a claim for long term disability benefits. She was counting on it to replace income for when she could not work. Now was the time.

She continued to seek medical care from several different physicians, each treating her for one aspect of her many medical issues. One doctor who was treating her for the rash said she needed to be off work for a couple weeks and then could return. However, her condition did not improve and so she was kept her off work for another 30 days. Unfortunately, after that her condition still did not improve completely. She had some improvement as to the rash and blood sugar, but other problems kept her too sick to be able to return to work.

Aetna said it was unclear whether she was disabled. So, Aetna asked the doctor treating Ms. Kendrick for the rash to complete an attending physician statement form. The completed form noted Ms. Kendrick could only lift 1-5 pounds frequently. Usually, to work a job you need to be able to lift at least 10 pounds for one third of the workday. Ms. Kendrick was still disabled and could not work. Aetna, however, did not feel that this was good enough. It contended there were no objective findings to support this opinion.

Another doctor, who was treating Ms. Kendrick for gastrointestinal problems, noted that she was still having those problems, but he did not complete the attending physician's statement for the plaintiff. Aetna said it was still unclear whether the plaintiff was disabled, but it paid benefits for a short time while it conducted its own record review with its own doctor. This doctor claimed to have spoken to two of the plaintiff's doctors. Aetna's doctor said that neither of the two treating doctors thought the plaintiff was disabled. He further said that one doctor could not remember filling out the attending physician's statement form. So, Aetna's doctor advised that Ms. Kendrick could perform her job. Aetna denied the claim.

Ms. Kendrick was understandably upset and appealed the decision to another department within Aetna and submitted additional medical information. However, she did not go back to her doctors to find out if they really did talk to the Aetna doctor. She did not provide any further medical opinions from those doctors who were treating her. Aetna denied the appeal. Aetna did not back down and Ms. Kendrick was denied her income replacement.

Still very upset, Ms. Kendrick then filed a lawsuit, but her case was lost. Aetna had the right to deny the claim if it had an any reasonable basis to support its decision, even if that decision was wrong. I am sure Ms. Kendrick was puzzled as to how her doctor could fill out a form and say that she was disabled, only to then hear that he told the insurance company's doctor that he didn't think she was disabled and could not remember filling out the form. In reading this opinion, we are left to wonder what happened.

The case underscores the necessity of diligent truth seeking during the claim process. Who knows if her doctors really did talk to Aetna's doctor? Who knows if her doctors really said what Aetna's doctor said? Who knows if Aetna's doctor was even talking about the right case with Ms. Kendrick's doctors, if that did occur? I have seen all three of those matters occur in different cases. It is critical to “do your homework” during the claim process before you file a lawsuit.

This case leaves so many questions unanswered. One is left with the impression that the claimant must have been malingering or even fraudulent. However, would any reasonable person go to this much trouble unless they were really disabled and in critical need? Some would say … yes to get a million dollars out of a lawsuit. There are no punitive damages and mental anguish damages allowed in these ERISA long-term disability cases. The court could only have awarded past due benefits to Ms. Kendrick. Also, maybe interest and reasonable attorney's fees. So, there was never a “big” lawsuit. And Aetna certainly knows this.

If you're curious about ERISA disability law, don't hesitate to get in touch with an attorney here at The Martin Law Group. We provide ERISA disability law services for folks throughout Mississippi and Alabama.

About the Author

David P. Martin

Senior & Managing Attorney


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