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Aetna Denial Overturned due to Failure to Conduct a Full and Fair Review

On Behalf of | Jan 8, 2019 | Appealing A Claim Denial |

Those who have filed insurance related claims have experienced the outcome-driven assessments in which insurance companies typically partake to determine an individual’s disability. A recent federal court case, Gorena v. Aetna Life Insurance Company (“Gorena“), is a prime example. Gorena was presented before the court on Ms. Gorena’s Motion for Summary Judgment. Ms. Gorena sought to order Aetna Life Insurance Company (“Aetna”) to approve and pay her long-term disability claim. In this case, the US District Court for the Western District of Washington at Seattle found that the denial of Ms. Gorena’s disability claim was wrongfully determined because Aetna misrepresented and ignored Ms. Gorena’s sufficient evidence which established her inability to perform her occupation.

Ms. Gorena was a Staff Analyst at Boeing between February 2005 and July 20, 2015. In 2007, she was diagnosed with multiple sclerosis (“MS”). Although Ms. Gorena’s disability request was solely rooted in her MS, she also suffered from chronic lumbar back pain, joint pain, polycystic ovarian syndrome, morbid obesity, gastrointestinal difficulties, depression and substance abuse. As a result of these ailments, Ms. Gorena had two ER visits, received numerous steroid injections to treat her MS, and had to take six insurance approved short-term medical leaves for MS symptoms (“STD” or Short Term Disability). On July 20, 2015, as a result of her worsening condition and inability to work, Ms. Gorena filed her Long Term Disability (“LTD”) claim with at the recommendation of her physician, a well-respected practitioner that taught other physicians and conducted MS research.

In response to her LTD claim, Aetna requested additional records and clinical consultations. Her attending doctor, submitted multiple MRI reports and documents which supported Ms. Gorena’s diminished functionality, numerous physical cognitive problems, and her inability to continue working. Ms. Gorena’s doctor opined that her physical impairment was rated as Class 5, an increased decline in her health was likely, and the cumulative effect of living with MS for so many years would make it impossible for her to maintain employment. Additionally, both a psychologist and a psychiatrist agreed Ms. Gorena was unable to work because of a mood disorder as a result of her medical condition. Notwithstanding this substantial evidence supporting Ms. Gorena’s inability to perform her occupation, Aetna denied her LTD claim on January 24, 2016 stating that her “intact strength, coordination, and no spasticity with only mild sensory issues to her feet” enabled her to perform sedentary work. Ms. Gorena appealed the denial, and again submitted additional evidence from her doctor supporting her inability to work. However, Aetna, upon review of the appeal concluded their decision was correct. Moreover, Aetna attempted to diminish her illness and delay payment of Ms. Gorena’s claim by characterizing the findings of her doctors as “advocating for EE(employee)’s disability.” In response to her wrongful denial, Ms. Gorena filed suit under ERISA (Employee Retirement Insurance Act of 1974).

The plan administrators, under ERISA are responsible for carrying out their discretionary duties in the best interest of the participants of the plan and for the exclusive purpose of providing benefits to participants. The court in Gorena found that Aetna’s conduct fell well below their set standard. The court recognized that Aetna, in an attempt to support their wrongful denial, blatantly ignored the multiple medical MRI reports and clinical findings documenting the increasing severity of her MS and misstated that Ms. Gorena’s negative symptoms were a product of anything but her MS. Moreover, the court stated that Aetna cherry-picked multiple statements out of context to disprove Ms. Gorena’s doctors’ conclusion and support their assessment of her fitness for work. The court, through these observations, saw through Aetna’s assessments to avoid payment, and overturned the denial of benefits, noting that Aetna ignored, misstated and cherry-picked evidence to support their own assessment of Ms. Gorena’s ability to work, while discounting the overwhelming evidence supporting the contrary.