Opinion ID: 752912
Heading Depth: 2
Heading Rank: 3

Heading: Aetna's First Denial

Text: 14 On November 17, Aetna denied Ace's claim. In the denial letter, Stephen Elliott (Elliott), Aetna's account specialist, informed Ace that 15 [i]n order to be eligible for Long-term Disability Benefits, you must be totally disabled to the extent that you are unable to work at any gainful occupation due to bodily injury or illness. 16 He noted that according to the Statement-the most current medical evidence on file-Ace was capable of continuing her employment as a loan examiner because she could perform clerical, sedentary work. Therefore, he wrote, we cannot consider you as being totally disabled from performing the duties of any gainful occupation as required by the policy, and denied her request for benefits. 17 Neither Elliott nor any other Aetna employee investigated Ace's claim other than to review the material sent by Ace. Elliott did have the material reviewed by Dr. John Galvin, an Aetna medical consultant, who reported that Ace had not established that she had a long-term disability. But Elliott did not contact Ace's medical care providers or obtain additional medical records, though Ace had signed a release. In determining the physical nature of Ace's occupation, Elliott relied entirely on Aetna's Physical Demands Analysis worksheet, ignored the more complete description that was attached, 6 and did not contact Ace or her supervisor to discuss her job's physical requirements. 18 The unable to work at any gainful employment phrase in Elliott's letter is drawn from Aetna's policy. In his deposition, Elliott testified he understood Aetna's policy to require Ace to be totally disabled from any gainful employment and unable to do ... any work, though he added that he would have denied her application even if he believed that Ace could only have worked half-time. Elliott's supervisor, Bryan Southall (Southall), testified, however, that he knew Aetna could not apply the unable to work at any gainful employment language literally, and that Aetna did not apply it literally in Ace's case. 7 Both he and Elliott testified Aetna applied a reasonableness test in evaluating disability. 8 Aetna conceded at trial, however, that no one from Aetna ever told Ace that the policy was not being interpreted and applied literally. 9 Ace testified she had called Aetna several times, but no one would clarify the term disabled or suggest specific documents she should send. Based on what she had been told in the letter, she would have to be totally disabled to be eligible for benefits; she knew that her condition was not that bad but also that it did not permit her to perform her job.