"Wong V. Aetna Life Insurance Company"

"Wong v. Aetna Life Insurance Company"

51 F. Supp. 3d 951 (S.D. Cal. 2014)

Ms. Wong was a regional facility manager at the Hobart West Group, which was insured by Aetna. After she gave birth to a child she began suffering from back leg and groin pain; her doctor placed her on disability referencing marked pain and stating she had no ability to work. Aetna granted LTD benefits and paid those benefits for nearly five years. Aetna then terminated those benefits and denied Ms. Wong's appeal. Thereafter the Social Security Administration retroactively awarded Ms. Wong Social Security Disability benefits.

At that point Ms. Wong hired us and we filed suit. The district court held that Aetna abused its discretion by terminating Ms. Wong's benefits, reasoning:

1. Aetna's reliance on an FCE in its termination of benefits was unreasonable because the physical therapist inappropriately claimed that Ms. Wong was fabricating or exaggerating the extent of her pain and because Aetna itself recognized in one document that Ms. Wong was not doing so. The Court concluded that it was unreasonable for Aetna to rely so heavily upon the FCE as evidence of symptom magnification when its own records indicated otherwise.

2. Aetna unreasonably based its decision on an anonymous and potentially unqualified physician's corroboration of the physical therapist's conclusions.

3. Aetna's decision improperly misconstrued the opinions and behavior of Ms. Wong's treating physician. Aetna asked Ms. Wong's treating physician to comment on the FCE report but did not give him a deadline for doing so or offer to pay him for his time. The Court explained that "it is left with a distinct impression that this approach was calculated to encourage no reply or an affirmative reply. The letter outlines a time-consuming procedure for Dr. Nelson to perform if he does not agree with Aetna's version of events."

4. Aetna improperly denied Ms. Wong notice of her physician's claimed unexplained change of prognosis which Aetna claimed it obtained over the phone immediately before the denial and only reported to Ms. Wong through the final denial and only second hand through the report of the reviewing doctor.

5. Aetna improperly used evidence that four years prior to the termination of her benefits Ms. Wong could walk and had good x-ray results as new reasons for the denial, which reasons it had not given Ms. Wong previous notice.

6. Aetna improperly used the opinion of an orthopedic surgeon who chiefly based his opinion on surveillance video of Wong of which she had never been made aware.

7. Aetna improperly shifted the reason for its denial away from a suggestion that Ms. Wong was fabricating her pain and toward a requirement for objective evidence that overlooked her symptomatic complaint as reported by her treating physician.

The Court ordered retroactive reinstatement of Ms. Wong's benefits.