Katherine Kochanek v. Aetna Life Insurance Co. and Home Depot U.S.A., Inc. – Court Affirms Insurance Company’s Decision to Deny Claim Due to Lack of Medical Evidence

Katherine Kochanek (“Kochanek”) worked as an employee of Home Depot U.S.A., Inc. (“Home Depot”). Through her employment, she was covered by the Home Depot Welfare Benefits Plan which included short-term disability benefits. Aetna Life Insurance Co. (“Aetna”) served as the administrator of the Plan. Under the Plan, a “disability” is considered to be any pregnancy-related condition, injury, or illness that prevents a person from carrying out her job duties. This means that she is doing only some of her job duties and that her income is 80% or less of her predisability earnings because of the pregnancy-related condition, injury, or illness.

On April 29, 2014, Kochanek applied for short-term disability benefits because of splenomegaly and Epstein-Barr virus. She supplied Aetna with an authorization that allowed it to access her medical information and it then requested a statement from Dr. Derek Bryant, her treating physician. Dr. Bryant forwarded information stating that Kochanek had both splenomegaly and Epstien-Barr virus, as well as issues with fatigue, fever, and abdominal swelling around January 30, 2014, and that Kochanek had “[n]o ability to work” from April 24 to July 1. He did not supply any medical records or physical exam findings, but explained that Kochanek was to see a gastroenterologist.

Aetna stated that Dr. Bryant needed to provide objective physical examination findings in order to show that Kochanek could not perform her job duties. Dr. Bryant responded by sending (1) a CT scan showing “[m]ild fatty infiltration of the liver and mild splenomegaly,” (2) an Anti-Nuclear ABS test indicating Epstein-Barr virus levels, (3) records showing an enlarged spleen, diabetes, stomach pain, general pain, diarrhea, and fatigue, and (4) records stating that Kochanek had stomach acid, bloating, heart palpitations, and nausea. Dr. Bryant also referred Kochanek to a Dr. Angelo Coppola and prescribed several medications for her.

Upon review of this information, Aetna said that “the medical data received does not support a functional impairment. We did not find specific physical examination findings which would preclude the associate from performing the core elements of her own job.” However, Aetna did grant the benefits through June 5 because of a meeting with Dr. Coppola and an examination of Kochanek’s job duties. Aetna further explained that it would not provide Kochanek with additional benefits without more information to support her benefits claim.

Aetna also received a report from Dr. Coppola from June 5, 2014, which explained that Kochanek experienced antral gastritis. As a result, he explained that Kochanek would not be able to go back to work until August 1 because of weakness and nausea. When Aetna asked Dr. Coppola whether Kochanek had any specific restrictions, he stated that he was waiting for test results. Aetna again chose to grant further benefits through July 6, stating that Kochanek must provide objective evidence to continue to receive benefits. At this point, Kochanek had still not received her test results, so Aetna extended the benefits through August 4.

As of August 5, Aetna denied Kochanek’s benefits because it received information from her doctors. The information did not support Kochanek’s inability to work. In fact, Dr. Coppola said that she was able to return to work as of July 3 and that she could participate in “[h]eavy work activity” with no limitations or restrictions. Dr. Bryant disagreed with this, however, could not provide any limitations or restrictions that would stop Kochanek from going back to her job.  Kochanek then filed an appeal of the denial. During this process, Aetna gave Dr. Edward Klotz Kochanek’s file for review. He determined that she was not disabled and had no impairments. He then spoke with Dr. Bryant who was unable to give any objective findings. Aetna then denied the appeal and Kochanek filed the instant suit.

After a review of the record, the Court determined that there was enough evidence to support Aetna’s termination decision. In particular, Dr. Bryant was never able to provide any medical evidence or documentation to support his assertions that Kochanek was unable to work. When Dr. Klotz reviewed the file, he found that Kochanek did not have an enlarged spleen anymore, and that there were no abnormal findings that would result in an impairment. Overall, the Court decided that there was a lack of evidence to indicate that Kochanek was unable to work and entitled to short-term disability benefits. It agreed that this was sufficient for Aetna’s denial of Kochanek’s claim, citing that because the decision “is supported by a reasonable explanation, it [will] not be disturbed.”

Kochanek also attempted to persuade the Court of several arguments. She first alleged that Aetna should not have been able to make any claims determinations. However, the Court cited that the record indicates that Aetna had the full authority to do so. Next, Kochanek argued that Aetna should have borne the burden of proof showing that she was able to do her job. The Court countered this argument with the language of the Plan, explaining that Kochanek was instead required to prove her disability.

Kochanek further provided case law that alleged she did not need to provide objective evidence to support her disability. The Court explained that the case she cited did not apply because that plan’s language was different than that of the immediate suit. A fourth argument that Kochanek brought was that Aetna had not discussed the side effects of her medication. However, the record lacked any indication of medication side effects preventing Kochanek from working.

Kochanek also argued that because Aetna initially approved her claim, that she should continue to receive benefits. The Plan language itself, however, required proof of a continued disability. Lastly, Kochanek claimed that her file should have been reviewed by an independent doctor before termination of her benefits. The language of the Plan does not require this, so they court did not agree with her argument. In the end, the Court disagreed with all of Kochanek’s claims and agreed with Aetna’s denial of her benefits. Therefore, it ruled in favor of Aetna and dismissed the suit.

[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]

Here is a copy of the decision in PDF:

Kochanek v. Aetna

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