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“Dunda V. Aetna Life Insurance Company”

Dunda v. Aetna Life Insurance Company”

2016 U.S. District Lexis 85549 (W.D. N.Y. June 30, 2016)

Ms. Dunda was the general manager of a retail store when she became disabled by chronic back pain. Aetna, the Long-Term Disability (“LTD”) insurer for Ms. Dunda’s employer, paid 24 months of “own occupation” benefits and more than four years of “any occupation” benefits, but then terminated Ms. Dunda’s benefits and denied her appeal. Ms. Dunda then hired us.

We filed suit and the District Court agreed with our arguments and ordered that Ms. Dunda’s benefits be retroactively reinstated. The District Court found that Aetna failed to provide Ms. Dunda with a full and fair review of her claim by requiring an “objective support for her medical conditions” even though the policy did not require such proof and the law recognizes that objective complaints alone may constitute sufficient evidence of disability. The Court explained that Aetna granted and paid Ms. Dunda’s LTD benefits under the more stringent, “any occupation” disability standards for over four years, based on essentially the same medical evidence that it discredited as “not objective” and therefore insufficient to support a finding of disability. Second, the Court found that Aetna abused its discretion by failing to consider Ms. Dunda’s SSDI award and by failing to have its medical consultant consider it. Third, although recognizing that an in-person medical examination (Independent Medical Examination or “IME”) is not required, the court held that it was an abuse of discretion not send Ms. Dunda for an IME because Aetna’s internal claims reviewer and its medical consultant based their rejection of Ms. Dunda’s claim solely on the absence of objective findings to corroborate her complaints of intractable pain and thus it was apparent that in Aetna’s opinion, Ms. Dunda’s claim for LTD benefits stood or failed on the credibility of those subjective complaints. Since the policy allowed Aetna to do an IME, its decision not to do one supports the finding that its determination was arbitrary and capricious.