{"id":7532,"date":"2020-04-22T18:09:26","date_gmt":"2020-04-22T23:09:26","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7532"},"modified":"2024-01-04T17:30:55","modified_gmt":"2024-01-04T22:30:55","slug":"mercado-v-aetna-court-holds-that-ltd-claim-denial-was-reasonable","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/mercado-v-aetna-court-holds-that-ltd-claim-denial-was-reasonable\/","title":{"rendered":"Mercado v. Aetna – Court Holds That LTD Claim Denial Was Reasonable"},"content":{"rendered":"

Case Name:\u00a0<\/strong>Armando Mercado v. Federal Express Corporation and Aetna Life Insurance Company<\/p>\n

Court:\u00a0<\/strong>United States District Court Southern District of Florida<\/p>\n

Type of Claim:\u00a0<\/strong>Long-Term Disability<\/a><\/p>\n

Insurance Company:\u00a0<\/strong>Aetna Life Insurance Company<\/a><\/p>\n

Claimant\u2019s Employer:\u00a0<\/strong>Federal Express Corporation \u201cFed Ex\u201d<\/p>\n

Claimant\u2019s Occupation \/ Job Position:\u00a0<\/strong>Operations Manager<\/a><\/p>\n

Disabilities: <\/strong>The plaintiff\u00a0suffered from\u00a0avascular necrosis in his hips<\/a>,\u00a0back pain<\/a>,\u00a0spinal stenosis,\u00a0obstructive sleep apnea<\/a>, and\u00a0gastroesophageal reflux disease<\/a>. The plaintiff underwent surgeries on his ankles and elbows. Plaintiff also suffers from polyneuropathy in his lower extremities and requires the use of a machine to deal with his obstructive sleep apnea.<\/p>\n

Definition of Disability: <\/strong>The LTD Plan defines Disability for the first two years as follows:<\/p>\n

\u201cthe employee has an \u2018Occupational Disability\u2019 under the LTD Plan that prevents a disabled employee from \u2018performing the duties of his regular occupation.\u201d<\/p>\n

The Plan allows an employee to receive LTD benefits beyond two years if the employee:<\/p>\n

\u201c[has] a \u2018Total Disability’ . . . that prevents him from working in \u2018any compensable employment\u2019 for at least twenty-five hours a week.\u201d<\/p>\n

Benefits Paid?\u00a0<\/strong>Plaintiff received short-term disability benefits from April 2012 to October 2012. Plaintiff received long-term disability benefits from October 2012 to October 2014 based on Aetna\u2019s determination that there were \u201csignificant objective findings\u201d that Mercado had an \u201cOccupational Disability\u201d as defined under the Policy.<\/p>\n

Procedural history:\u00a0<\/strong>Plaintiff was approved for long-term disability benefits from October 2012 to October 2014, at which point Aetna decided to cease Plaintiff\u2019s long-term disability benefits after his two-year benefits period expired. Plaintiff appealed Aetna\u2019s decision and received a denial of his appeal in November 2014. Aetna informed Plaintiff that he did not meet the definition of \u201cTotal Disability\u201d based on the Policy\u2019s definition of long-term disability after the first two years of benefits.<\/p>\n

Key Physician Opinions: The plaintiff<\/strong>\u00a0had various physicians offer their assessment of the Plaintiff\u2019s condition during his claim\u2019s process for long-term disability. The Social Security Administration found in February of 2014 that Plaintiff was \u201cable to stand and\/or walk 1 hour total in an 8-hour work day, [and] sit 4 hours total in an 8-hour work day.\u201d The Veteran Affairs Outpatient Clinic, Plaintiff\u2019s primary treating facility, opined that Plaintiff\u2019s degenerative arthritis in his ankles would prevent \u201cphysical . . . but not sedentary employment.\u201d Additionally, the Clinic determined that the Plaintiff\u2019s back condition would \u201cprevent all physical and sedentary employment.\u201d<\/p>\n

Aetna utilized two peer review physicians to analyze Plaintiff\u2019s medical records and relative conditions. Dr. John-Paul Rue found that while Plaintiff did, in fact, suffer from various conditions and diseases in his lips and legs, his \u201cmedical conditions [were] controlled and not contributing to his overall functional impairment.\u201d He concluded that Plaintiff\u2019s medical records contained insufficient evidence severe enough to meet the Policy\u2019s definition of Total Disability, in that Plaintiff could engage in any compensable employment for a minimum of twenty-five hours a week. The second peer review physician Aetna utilized, Dr. Martin Mendelssohn, opined that despite Plaintiff\u2019s past and potential surgical procedures and pain management regimen, Plaintiff\u2019s medical records contained insufficient evidence to reveal that Plaintiff\u2019s functional impairments would \u201cpreclude the claimant from engaging in any compensable employment for a period of 25 hours per week provided with sedentary or light physical exertion level.\u201d<\/p>\n

Issues:\u00a0<\/strong>The Court addressed several issues within Aetna\u2019s determination that the Court found did not meet the required arbitrary and capricious standard.<\/p>\n

(1) Whether Aetna improperly ignored the Social Security Administration\u2019s findings.<\/p>\n

(2) Whether Aetna properly respected the Veteran Affairs Clinic physician\u2019s findings during the Plaintiff\u2019s compensation and pension review.<\/p>\n

(3) Whether the peer review physicians\u2019 reports relied upon by Aetna in issuing its denial of benefits were consistent and clear and supported the information contained in Plaintiff\u2019s medical records.<\/p>\n

Holdings:\u00a0<\/strong>The Court granted Defendant\u2019s Motion for Summary Judgment and affirmed Defendant\u2019s denial of continued long-term disability benefits to Plaintiff. The Court held the record supported Aetna\u2019s contention that Plaintiff was no longer entitled to LTD benefits because he failed to meet the definition of \u201cTotal Disability\u201d as defined by the Policy and that Aetna\u2019s decision to do so was neither arbitrary or capricious.<\/p>\n

(1) The Court held that based on the Social Security Administration and Aetna\u2019s different respective definitions of \u201cTotal Disability,\u201d Aetna\u2019s assessment of Plaintiff\u2019s limitations was reasonable in light of the Policy\u2019s definition of \u201cTotal Disability.\u201d<\/p>\n

(2) The Court held that Aetna did not act unreasonably in considering the Veteran Affairs Clinic\u2019s findings during the Plaintiff\u2019s compensation and pension review.<\/p>\n

(3) The Court determined that nothing in the peer review physician\u2019s reviews suggested that they ignored Plaintiff\u2019s medical records and treating physicians\u2019 conclusions and that Aetna\u2019s decision to agree with such reports was reasonable.<\/p>\n

Summary:\u00a0<\/strong>\u201cUnder the arbitrary and capricious standard, the review is limited to whether reasonable grounds existed to support Aetna\u2019s denial of benefits to [Plaintiff] based on the administrative record before it. See Townsend v. Delta Family-Care Disability and Survivorship Plan, 295 F. App\u2019x 971, 976 (11th Cir. 2008). The Court held that Aetna reasonably concluded that Plaintiff was no longer entitled to long-term disability benefits and that their decision process was neither arbitrary nor capricious. The Court granted Defendant\u2019s Motion for Summary Judgment and denied Plaintiff\u2019s Motion for Summary Judgment. Aetna\u2019s denial of continued long-term disability benefits was affirmed.<\/p>\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

Here is a PDF copy of the decision: Mercado v. FedEx & Aetna<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Under the arbitrary and capricious standard, the review is limited to whether reasonable grounds existed to support Aetna\u2019s denial of benefits based on the administrative record before it. The Court held that Aetna reasonably concluded that Plaintiff was no longer entitled to long-term disability benefits and that their decision process was neither arbitrary nor capricious. Aetna\u2019s denial of continued long-term disability benefits was affirmed.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[245],"_links":{"self":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7532"}],"collection":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/comments?post=7532"}],"version-history":[{"count":0,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7532\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/media?parent=7532"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/categories?post=7532"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/tags?post=7532"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}