Our client was insured under a self-funded long term disability plan which was administered by Aetna Life Insurance Company. Our client filed an LTD claim based on his anxiety, panic disorder and agoraphobia. Aetna initially approved the claim, but later terminated benefits and denied the claim.
We filed suit in Federal Court and the judge found that Aetna’s decision denying the LTD benefits was “arbitrary and capricious.” In its decision, the Court noted that our client had been approved for Social Security Disability benefits. Yet, Aetna did not consider the Administrative Law Judge’s findings when it terminated LTD benefits. This is in spite of the fact that the Plan requires its insureds to file for Social Security Disability, and also allows the Plan to take an offset for Social Security Disability benefits.
Further, the Court also found that Aetna had failed to advise the claimant that he should submit the Social Security records as evidence in support of his disability claim.
Finally, the Court found that Aetna acted arbitrarily because of its failure to have its own medical reviewers physically examine Mr. Roush as opposed to simply reviewing medical records. The Plan specifically allowed Aetna to require a physical examination.
As a result, the Court awarded benefits and remanded the matter to Aetna to continue paying long term disability benefits.