Opinion ID: 202829
Heading Depth: 2
Heading Rank: 2

Heading: Evidence Supporting the Denial of Benefits

Text: Under Aetna's LTD plan, an employee is ineligible for benefits if his disability began during the first twelve months of employment and was caused, or contributed to, by a `pre-existing condition.' See supra note 1. The plan defined pre-existing conditions as those for which the employee received diagnosis, treatment or services or took drugs prescribed or recommended by a physician during the three months prior to the beginning of coverage under the plan. Id. Aetna denied Kansky's claim for LTD benefits because it determined that his schizoaffective disorder caused or contributed to his disability in July 2003, and hence his schizoaffective disorder was a pre-existing condition under the terms of the plan. That decision was consistent with the overwhelming weight of the evidence in the administrative record. First, when Kansky initially applied for LTD benefits in February 2004, his treating physician, Dr. Vuckovic, attributed his disability to his schizoaffective disorder. Dr. Vuckovic had been continuously treating Kansky for that condition for four years and stated in his Attending Physician's Statement (which Kansky submitted to Aetna in support of his LTD benefits application) that the disability that began in July 2003 and continued to the present was attributable to that condition. This record, offered by Kansky and created contemporaneously with his application for benefits, provides strong evidence that Kansky himself, as well as his treating physician, attributed his disability to his schizoaffective disorder. Second, Kansky was hospitalized for a period of ten days between the onset of his disability and his application for LTD benefits. The discharge summary from this treatment stated that his primary diagnosis was atypical schizophrenia. The hospital did not diagnose Kansky with CFS. Third, Aetna sent Kansky's medical records to two board certified physicians for their review and evaluation. Each of them concluded that his primary diagnosis, schizoaffective disorder, was the primary cause of his disability. Each credited Dr. Vuckovic's opinion, based on his long-term treatment and evaluation of Kansky, and found that the records supported Dr. Vuckovic's impression of Kansky's medical problems rather than Dr. Bell's. Kansky argues, however, that his disability was caused exclusively by his CFS  an independent diagnosis, unrelated to his history of schizophrenia, and therefore not classifiable as a pre-existing condition. In support of his claim, he points to the two letters from Dr. Bell. The first letter, from July 2004, stated that Kansky's then-existing symptoms were very suggestive of chronic fatigue syndrome, and that CFS is a more accurate clinical diagnosis than his atypical schizophrenia. The letter also acknowledged, however, that Kansky would not fulfill the Centers for Disease Control criteria for chronic fatigue syndrome as he has a history of atypical schizophrenia. Dr. Bell recommended no alterations to Kansky's medications or treatment, and suggested only that he make an effort to establish a very regular sleep time and a regular time for arising. The second letter, dated January 2005, was much shorter and simply reiterated the findings stated in the July 2004 letter. It stated that Kansky's current disability is not due to the schizoaffective disorder; it is due to chronic fatigue syndrome. Neither letter purported to provide a diagnosis for Kansky's disability as of July 2003; both stated only that, at the time Dr. Bell saw him, Kansky's symptoms could be explained by CFS. Therefore, even if we were to credit Dr. Bell's letters and assume that his diagnosis was accurate, he simply did not opine that Kansky suffered from CFS at the time his disability began. Furthermore, Dr. Bell never offered an opinion, one way or the other, as to whether Kansky's well-documented schizoaffective disorder contributed to his disability. By contrast, every treating physician who saw Kansky stated that his medical problems were the result of his schizoaffective disorder, or complications arising from that disorder. The independent medical professionals who examined Kansky's records and provided their opinions to Aetna agreed with this diagnosis. On this record, there is simply no doubt that Kansky's schizoaffective disorder, for which he had received treatment during the three months prior to commencement of the LTD plan, either caused or contributed to his disability. We find no error in Aetna's denial of benefits on this basis.