Opinion ID: 752912
Heading Depth: 2
Heading Rank: 6

Heading: Ace's Response to Aetna's Second Response

Text: 25 Although Aetna's December 11 letter did not state that the claim had again been denied, it was the functional equivalent of a denial. When Ace received this letter, she had been without income since her short-term disability benefits expired in September and had begun to sell her personal property. She consulted a lawyer, Francine Harbour (Harbour), who wrote to Aetna on Ace's behalf to facilitate the review process in this matter. Harbour's letter stated that Ace believed she already had furnished objective medical evidence but would submit additional information to clarify any misunderstanding. To that end she requested that Aetna send to her the pertinent claim adjustment guidelines that [Aetna] relied on in reaching [the] denial determination and certain other material. She asked Aetna to provide the documents prior to her sending additional information, so that she could ensure that her submission was complete. 26 Southall responded to Harbour's request on January 28, 1993, stating, There are no claim adjustment guidelines which we follow. During discovery, however, Aetna produced its Proper Claim Handling Guidelines contained in its Methods and Procedures Manual, 12 and at trial Aetna's director of disability claims testified that the guidelines are mandatory for its claim analysts to follow. 27