If you are in the process of claiming long-term disability benefits it can be difficult to understand why denied your claim. During the review, the insurer asks you to provide medical evidence of your disability, and at times this evidence may be mischaracterized by a medical consultant who will complete a file-only review of your disability, without every contacting your treating physicians or evaluating you in person. Worse, these file reviewers will sometimes ignore objectively determined limitations from a functional capacity evaluation to urge the insurer to not pay the long-term disability insurance.
In Coulter v. Aetna Life Ins. Co., No. 14-CV-14404, 2016 U.S. Dist. LEXIS 23482 (E.D. Mich. Feb. 26, 2016), Sharon Coulter worked for Alcoa Inc. as a manufacturer in the automotive division and became disabled due to bilateral carpal tunnel syndrome. Aetna awarded Coulter disability benefits for the first 24 months while she was disabled from performing her own occupation. But then Aetna had to determine if Coulter was disabled from performing “any occupation” for which she is reasonably suited by training, education, or experience. Coulter submitted additional medical evidence, including three functional capacity evaluations (“FCEs”).
The first FCE, taken while the definition of disabled was still based on Coulter’s “own occupation” of auto manufacturer, indicated Coulter could perform medium physical exertion level work. But the two subsequent FCEs were conducted after the definition changed to an “any occupation” standard and indicated Coulter only had physical capacity to perform sedentary level work. Aetna’s hired medical consultant opined Coulter could perform light-to-medium physical exertion level work, despite the most recent FCE restricting Coulter to sedentary level work. Aetna then relied on this flawed opinion to deny Coulter further long-term disability insurance benefits. Coulter sued for benefits under ERISA § 502(a). The court deemed Aetna’s reliance on such a medical opinion in the face of the contrary objective limitations determined by the FCE unreasonable.
If your claim for long-term disability insurance has been denied following a review by an insurer’s hired medical consultant, speak with a knowledgeable ERISA long-term disability attorney today.