Aetna wrong on man's disability benefits, judge says
Steve Korris Mar. 31, 2011, 2:36am
CHARLESTON – Aetna Life Insurance improperly denied disability benefits to former Bristol Myers Squibb manager Ricky Dickens without explaining why it disregarded a Social Security Administration decision in his favor, U.S. District Judge Thomas Johnston ruled on March 28.
"Aetna's cursory treatment of the SSA decision suggests an unfair decision making process, where it seems the long term disability plan administrator is merely going through the motions rather than appropriately considering the relevant evidence," he wrote.
He remanded the matter to Aetna.
Bristol Myers Squibb hired Dickens in 2002, as a senior territory business manager responsible for marketing drugs to doctors and hospitals.
In 2004, he suffered depression, anxiety, and insomnia, leading to suicidal ideas.
He applied to Aetna for long term disability, and he received benefits for four years.
Aetna terminated his benefits in 2008, finding he no longer suffered from injury or illness.
He sued in 2009, in Fayette Circuit Court, seeking restoration of benefits and an injunction preventing Aetna from discontinuing them. Aetna removed the suit to U.S. District Court last year, pursuant to the federal Employee Retirement Income Security Act.
Both sides moved for summary judgment, and Johnston granted it to Dickens.
"The Social Security Administration continues to consider plaintiff disabled under relevant law," Johnston wrote. "Social Security disability awards are not binding on ERISA plan administrators.
"However, SSA determinations are not worthless, either."
He wrote that when definitions of disability are similar, "a plan administrator's failure to consider the SSA award in making the ERISA plan decision is an abuse of discretion."
He wrote that Social Security's definition restricts eligibility to those who can't perform any substantial gainful work in the national economy.
Johnston wrote that Aetna's definition permits benefits for anyone who is precluded from performing any job for which he or she is reasonably qualified by education and experience.
He wrote that it was more difficult to show disability under Social Security's definition.
"Not only did Aetna fail to afford the SSA determination substantial weight, it ostensibly neglected to weigh the decision at all," he wrote. "Aetna's error regarding the SSA determination is severely compounded when juxtaposed with the fact that Aetna required plaintiff to initially apply for and fully appeal any denial of Social Security disability benefits."
He wrote that Aetna offsets its disability benefits by Social Security benefits.
"Aetna retroactively imposed the offset provision on plaintiff when he became eligible for disability benefits under the SSA," he wrote. "The fact that Aetna mandated plaintiff's application for SSA disability benefits and then financially benefited from the award of those benefits only serves to bring the fundamental unfairness of Aetna's actions into sharper relief."
He found Aetna's treatment of Dickens arbitrary, unreasonable, and fatally flawed.
He denied attorney fees to Dickens, ruling that he expressed no opinion as to whether Dickens is disabled under Aetna's definition.
"Instead, the remand in this case represents a purely procedural victory for plaintiff, and attorney's fees are not warranted at this time," he wrote.
Harry Bell, Jeff Stewart and Robert Absten, all of the Bell Law Firm in Charleston, represented Dickens.
Grant Shuman and Joseph Garcia, both of Spilman, Thomas and Battle in Charleston, represented Aetna.