After Kantor & Kantor helped a client recover her long term disability benefits on appeal, Aetna decided that no further benefits would be provided unless the client filed a lawsuit. Kantor & Kantor obliged. The attorneys defending Aetna’s actions must now show good cause to a Federal Judge explaining Aetna’s actions.
Our client started working for Bristol-Myers Squibb in 1989 – staying with the company until she became disabled in November 2010. At that time our client’s doctors determined she was no longer able to work due to a multitude of medical conditions including post-traumatic stress syndrome, depression, anxiety, hypertension, a right knee injury, lumbar strain, and insomnia.
After our client submitted a claim for disability plan benefits, Aetna (the insurance policy’s claim administrator) found her to be disabled under the terms of the plan and long term disability benefits were paid. The Social Security Administration also found our client to be disabled and has continued finding her disabled.
After one year of benefits, the disability insurance policy definition of disability required the claimant to be disabled from “any occupation” to receive benefits (rather than just her "own occupation"). Even still, in October 2011, Aetna determined our client was entitled to plan benefits under the “any occupation” definition of disability.
In March 2013, Aetna terminated our client’s LTD benefits effective April 1, 2013. Aetna provided our client with an opportunity to appeal its determination. Our client hired us to help her submit her appeal.
An appeal was submitted in September 2013. In order to help prove our client was disabled from any occupation, Kantor & Kantor had her undergo an independent neuropsychological examination. The testing objectively confirmed our client’s continued disability. Kantor & Kantor had the objective medical evidence reviewed by an independent vocational reviewer. This further confirmed there were no feasible occupations that our client could currently perform.
In October 2013, Aetna upheld the termination of benefits. Aetna failed to address our independent neuropsychological examination or independent vocational review. Aetna offered one final opportunity to appeal. Aetna stated that in the event an appeal was submitted, “If the decision is unchanged at the completion of the review process and you or your client continue to disagree with our decision, you or your client have the right to bring a civil action….” (emphasis added)
In April 2014, Kantor & Kantor submitted another appeal challenging Aetna’s benefit termination. Along with the appeal Kantor & Kantor submitted additional medical evidence showing our client’s continued disability from April 1, 2012 through the present.
Aetna responded to the appeal in four versions of the same letter – two dated July 24, 2014 and two dated July 28, 2014 – all authored by Linda Camacho. A different letter dated July 28, 2014 was also submitted and authored by Joann Harrigan. All five letters changed Aetna’s decision to terminate benefits effective April 1, 2013, and Aetna now agreed to pay benefits up to May 01, 2014.” Aetna now terminated all benefits effective May 2, 2014. The basis for the new termination date was a lack of medical information as of that date.
Despite the fact that the April 1, 2013 termination of benefits had been completely overturned, with benefits reinstated, Aetna did not give our client the option of another administrative appeal. Aetna did not request the missing information as required by the Plan’s terms. Aetna did not give our client the opportunity to provide the “missing” information as required by the Plan’s terms. Rather, Aetna stated “[a]ccording to your client’s group plan, this decision is final and not subject to further review.” Aetna did not provide the Plan term supporting this statement, and it could not, as no such term exists in the Plan.
Aetna stated that if our client disagreed with the new decision, her only option was to file a civil action under ERISA. With no other option, Kantor & Kantor filed a lawsuit in the Federal District Court in the Central District of California. The case was assigned to a judge sitting in Los Angeles. Bristol-Myers Squibb hired a Morgan Lewis, a 2,000 lawyer multi-national law firm, to defend the plan and Aetna’s actions.
Because our client was not provided with a full and fair review, Kantor and Kantor immediately initiated legal proceedings to prove in court that Aetna had acted wrongfully and our client’s claim should be remanded for further evaluation. The attorneys at Morgan Lewis resisted, claiming Aetna’s termination of benefits was not improper. With the first opportunity to present the basic issue to the Court, Kantor and Kantor did so.
The court saw the logic in Kantor and Kantor’s arguments. Without even having a hearing, the court issued an order to show cause in which Bristol-Myers Squibb Co. had to explain why Aetna’s actions and the law did not dictate a remand.