{"id":7531,"date":"2020-04-22T17:27:18","date_gmt":"2020-04-22T22:27:18","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7531"},"modified":"2024-01-30T14:52:33","modified_gmt":"2024-01-30T19:52:33","slug":"mendez-v-aetna-aetna-had-a-conflict-of-interest","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/mendez-v-aetna-aetna-had-a-conflict-of-interest\/","title":{"rendered":"Mendez v. Aetna – Aetna Had a Conflict of Interest"},"content":{"rendered":"\n
Case Name: <\/strong>Miguel Mendez v. Federal Express and Aetna Life Insurance Company<\/p>\n\n\n\n Court: <\/strong>United States District Court for the Eastern District of Michigan<\/p>\n\n\n\n Type of Claim:\u00a0<\/strong>Long-Term Disability<\/a><\/p>\n\n\n\n Insurance Company: <\/strong>Aetna Life Insurance Company<\/a><\/p>\n\n\n\n Claimant\u2019s Employer: <\/strong>FedEx Express<\/p>\n\n\n\n Claimant\u2019s Occupation \/ Job Position: <\/strong>Delivery Driver<\/p>\n\n\n\n Disabilities:\u00a0<\/strong>On July 14, 2012, Plaintiff was involved in a catastrophic accident that caused several severe orthopedic injuries, including a splintering of his pelvis. The Plaintiff suffered from a\u00a0traumatic brain injury\u00a0as a result of his on-the-job accident. The Plaintiff also suffered from chronic daily pain in the\u00a0neck,\u00a0back, pelvis, right leg, shoulders, and groin areas. Despite undergoing two significant orthopedic surgeries, Plaintiff suffered from headaches, muscle spasms in his back, and decreased sensation in both lower extremities at L5-S1 and in bilateral sacroiliac joints and right acromioclavicular joint. The Review Committee\u2019s report stated Plaintiff had \u201csustained a fractured pelvis, acetabular fractures, is status post open reduction and internal fixation, has a diagnosis of traumatic brain injury<\/a> and late effects of traumatic brain injury, right AC joint separation, left first rib fracture, neuropathic pain of the bilateral lower extremities, chronic back pain<\/a> and insomnia<\/a>.\u201d<\/p>\n\n\n\n Definition of Disability: <\/strong>The Plan defines Total Disability as \u201cthe complete inability . . ., because of a medically determinable physical or functional impairment (other than an impairment caused by a mental or nervous condition or a chemical dependency), to engage in any compensable employment for twenty-five hours per week.\u201d<\/p>\n\n\n\n Benefits Paid?\u00a0<\/strong>Plaintiff received short-term disability benefits from July 23, 2012, to January 20, 2013. On January 20, 2013, Plaintiff began receiving long-term disability benefits based on his inability to work in his previous position. Aetna paid Plaintiff long-term Occupational Disability benefits for the entire available period, two years, from January 21, 2013, to January 20, 2015. Under the Plan, Aetna required Plaintiff to apply for Social Security Disability Income, and in May 2013, Plaintiff was rendered totally disabled and awarded SSDI.<\/p>\n\n\n\n Procedural history:\u00a0<\/strong>The claimant was denied coverage on January 21, 2015, after Aetna determined that he did not meet the definition of Totally Disabled. Plaintiff appealed the decision to the Aetna Appeal Review Committee. In March 2014, the Review Committee upheld the denial of Plaintiff\u2019s Total Disability claim.<\/p>\n\n\n\n Key Physician Opinions:\u00a0<\/strong>Dr. James Wallquist, an orthopedic surgeon, concluded that insufficient objective medical evidence showed that Plaintiff could not work at least twenty-five hours per week. Dr. John P. Shallcross, a neuropsychologist, concluded the same finding that there was no documentation of Plaintiff\u2019s \u201cmental and nervous condition from 5\/3\/13 forward\u201d and \u201cno assessment of [Plaintiff\u2019s] psychiatric state sufficient to diagnose an Adjustment Disorder.\u201d Dr Martin Mendelssohn, a retired orthopedic surgeon, concluded that there were insufficient objective findings that Plaintiff could not work at least twenty-five hours per week, based on his review of Plaintiff\u2019s file.<\/p>\n\n\n\n After an MRI was conducted, his treating physician made the following conclusions:<\/p>\n\n\n\n Issues: <\/strong>The Court addressed several issues within Aetna\u2019s determination that the Court found were arbitrary and capricious.<\/p>\n\n\n\n Holdings:\u00a0<\/strong>The Court concluded that Plaintiff was denied benefits \u201cto which he is clearly entitled.\u201d Aetna\u2019s decision to deny Plaintiff\u2019s claim for long-term disability was arbitrary and capricious and incorrectly cut off Plaintiff\u2019s long-term disability benefits.<\/p>\n\n\n\n The Court noted that the repeat physicians discounted extensive medical documentation of chronic pain and a myriad of other ailments as stated by the Plaintiff\u2019s treating physicians. In conclusion, the Court ordered Aetna to pay Plaintiff the long-term disability benefits he qualified for and ordered Plaintiff to submit a briefing regarding back-due benefits, applicable interest, and any other costs and fees that are appropriate.<\/p>\n\n\n\n Summary:\u00a0<\/strong>The Court granted Plaintiff\u2019s Motion for Summary Judgment and denied Aetna\u2019s Motion for Summary Judgment. The Court found Aetna\u2019s denial of Plaintiff\u2019s claim for long-term disability to be arbitrary and capricious and ordered Aetna to pay the long-term disability benefits for which he is qualified under the Plan. Specifically, the Court stated, \u201cwithout ever examining [Plaintiff], the Plan should not have made a credibility determination about his continuous reports of pain.\u201d Coupled with Aetna\u2019s lack of adequately explaining why the Plaintiff\u2019s award of SSDI was not distinguished and the conflict of interest that arose due to the reviewing physicians\u2019 deep entanglement with Aetna, the Court concluded that Aetna\u2019s denial of long-term disability benefits was incorrect.<\/p>\n\n\n\n Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.<\/p>\n\n\n\n\n
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