Aetna Disability Claim Denials

Buying long-term disability insurance is a way of hedging your bets — of making payments every month to ensure that even if you get sick, have an accident or otherwise become disabled, you’ll be covered. Yet far too often, major insurance companies like Aetna deny legitimate claims for benefits all so they can turn a profit at the expense of individuals with disabilities.

There are many ways that Aetna and other insurers attempt to deny and delay coverage, such as by using policy limitations and exclusions against insureds. This can be incredibly frustrating, especially for anyone who is relying on those benefits to get them through a period of time when they are unable to work.

Yet there is hope — and help. A Philadelphia long-term disability insurance attorney can work with you to fight back against Aetna if they deny your claim in bad faith. Appealing a claim denial can help you get the coverage that you are entitled to, and allow you to move forward with your life.

Long-Term Disability Policies — and How Aetna May Try to Deny Coverage

Long-term disability is a type of insurance that provides individuals with a percentage of their income if they are unable to work for an extended period of time due to a covered illness or disability. Like other insurance companies, Aetna’s long-term disability policies limit the type of illnesses and disabilities that are covered.

For example, to qualify for these benefits, you will need to miss a certain number of days of work before your disability benefit begins to satisfy what is known as the elimination period. Aetna may also push you or even require you to undergo rehabilitation therapy to help you get back to work. Other income that you receive may limit the amount of benefits that you receive, which are determined by your annual salary and other factors, such as bonuses and commissions.

Aetna may also limit and exclude eligibility for long-term disability benefits based on mental health conditions or alcohol or substance abuse. It often also excludes disabilities caused by intentional, self-inflicted injuries, an act of war, a criminal act, or a car accident if you were driving under the influence at the time of the collision.

There are many reasons why Aetna may deny an individual’s long-term disability claim. It is important to consult your specific policy documents to determine what limitations and exclusions may be contained in it.

How to Appeal a Claim Denial from Aetna

Whether you are covered under an individual or group disability plan from Aetna, if you receive a claim denial letter, you likely have the right to appeal. Under the law, insurance companies issuing individual policies are required to act in good faith and to deal fairly with claimants. If they fail to do so — such as by looking for reasons to avoid paying legitimate claims — then they may have acted in bad faith.

There are a number of ways that an insurance company such as Aetna may act in bad faith. This may include misinterpreting the provisions of your policy, having a doctor in the wrong specialty perform an Independent Medical Examination (IME), or offering to settle your claim for far less than what you are entitled to under your policy.

In addition, Aetna’s treatment of a claim and an insured may violate the law. Most Aetna group policies (unlike individual policies), are covered by the Employee Retirement Income Security Act of 1974, more commonly known as ERISA. This federal law governs benefits provided to employees by private employers, including disability benefits. 

Under ERISA, insurance companies are required to comply with certain reporting and disclosure rules.  This means that Aetna has an obligation to ensure that you are aware of the provisions of your disability insurance policy in a way that the courts have deemed adequate. If Aetna fails to do so, then it could face legal consequences.

ERISA also sets forth complicated rules for appealing denials of claims. This includes a short deadline of filing an appeal, in writing, within 180 days of the denial. If you fail to do so, then you may not be able to file a lawsuit later if necessary.  You may also be prevented from adding new evidence if you don’t do so during your appeal window. 

Aetna has been sued a number of times for denying long-term disability benefits. In Ace v. Aetna Life Insurance Company, Sherrie Ace sued Aetna, alleging that they had acted in bad faith when denying her disability insurance benefits. The jury ruled in her favor, and on appeal, the appellate court found that Aetna had acted in bad faith in multiple different ways, including:

1. basing the denial of her claim on an illegal standard for benefit eligibility;
2. failing to investigate the claim and to seek or request the supporting information alleged to be missing; and
3. failing to inform her of the standard procedures used by Aetna in evaluating disability claims.

Fight Back Against Wrongful Disability Claim Denials

Like many insurance companies, Aetna has a track record of attempting to avoid responsibility for long-term disability insurance payments by denying legitimate claims. It can be frustrating to go through the long process of applying for benefits, only to be stymied at every turn by the insurance company. Our Philadelphia long-term disability insurance attorneys will help you take on Aetna — and increase your chances of a successful outcome.

Since 1995, Bross & Frankel has served residents of Pennsylvania and New Jersey who need aggressive advocates in their battle for the benefits that they deserve. We have the skill and the knowledge to get results. To learn more or to schedule a free claim review, contact our office today at (856) 795-8880, or online.