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TSA and No SSDI Record Leads to Remand – M.D. Ala

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  • TSA and No SSDI Record Leads to Remand – M.D. Ala

    Here’s a new case out of the Middle District of Alabama, Richard P. Shultz v. Aetna Life Insurance Company, et. al. The court first finds that plaintiff’s claim meets the first prong of the test.

    The court must first “[a]pply the de novo standard to determine whether the claim administrator’s benefits-denial decision is “wrong” (i.e., the court disagrees with the administrator's decision).” Blankenship, 644 F.3d at 1355. That prong is met. Aetna denied Plaintiff’s LTD benefits on the advice of an outside doctor who never saw the Plaintiff, made minimal and disputed effort to contact the Plaintiff’s two treating physicians, and placed no weight on the Plaintiff's treating physicians’ opinions. Even ignoring Dr. Antonelli’s assessments, Aetna made its decision to review whether Plaintiff was no longer disabled less than a year after Plaintiff had been approved for Social Security disability benefits specifically at Aetna’s suggestion and with their assistance. (Though Aetna must reach its own separate decision, it is notable that the Social Security Administration uses a standard of inability to perform any substantial gainful activity. This is a much more stringent standard than the “reasonable occupation” standard under the LTD policy.) Aetna ignored the suggestions of both Dr. McAllister and Dr. Antonelli that Plaintiff was in need of cognitive evaluation. Moreover, the record is replete with medical reports specifically stating that Plaintiff could “never” return to work at any level of skill, even on a part-time basis. Simply put, Aetna’s decision that Plaintiff was capable of working at all, much less 8 hours a day and 40 hours a week, has no reasonable basis or support in the extensive medical records before this court.
    The court then concludes that Aetna’s decision was arbitrary and capricious, but was based upon an incomplete record, lacking the Social Security file.

    As such, the issue before this court is whether it was arbitrary and capricious for the Aetna administrators to decide that Plaintiff, with a “huge” inoperable hernia, inoperable pulmonary emboli, chronic fatigue, a leaking stoma, limited mobility, limited physical ability, and showing signs, even by the independent doctor's review (who never laid eyes or hands on the Plaintiff), that Plaintiff was in need of cognitive testing, was capable of working a full-time job after being found totally disabled by the Social Security Administration, a determination which Aetna had suggested and supported. In reviewing this prong, the court notes that Aetna, in its effort to prove that Plaintiff could engage in a full-time job, determined that Plaintiff’s employment with L-3 as a Field Engineer III, “most closely correlates to the following occupation … Help Desk Supervisor,” i.e., one of the very occupations cited by Aetna as a “reasonable occupation” for Plaintiff based on the Transferrable Skills Assessment, and the basis for ending his LTD benefits. (Doc. 115-29 at 67). In other words, Aetna, by its own admission, determined that the prior occupation, from which Plaintiff was unquestionably disabled, was the direct equivalent of the “reasonable occupation” Aetna used to terminate those same LTD benefits.

    Moreover, as both parties note and argue, the administrator’s determination was made without benefit of the record that was before the Social Security Administration, the very record that was generated at Aetna’s suggestion and with Aetna’s assistance. Aetna was diligent in suggesting that Plaintiff apply for Social Security Disability Insurance benefits and equally diligent in recovering its share of those benefits once they were awarded to Plaintiff, but then failed to consider or include in the record the information that supported that award. Both parties could and should have used the administrative proceedings to more fully develop the record with the details they now wish to rely on for their respective positions. Accordingly, Aetna’s decision, on the record before this court, was not reasonable and, for that matter, was arbitrary and capricious, specifically because the record is unsatisfactory and both sides are entitled in the first instance to an administrative decision based on a proper record. Therefore, the appropriate remedy is remand with the opportunity to complete the record and obtain a new decision.
    The opinion is attached below.
    Attached Files