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Multiple Sclerosis Cases
Letvinuck v. Aetna Life Ins.Co., 319 Fed.Appx. 661 (9th Cir. June 22, 2011)(unpublished)
In approximately 2003, Letvinuck was diagnosed with Multiple Sclerosis, but continued to work despite symptoms of fatigue and cognitive decline. After attempting to work from home, Letvinuck submitted a claim for disability to her employer's claim administrator, Aetna. Aetna also funds the benefits to be paid under the Plan. Aetna initially approved Letvinuck's claim under the employer funded short term disability phase of the Plan. As Aetna's own liability approached, under the long term phase of the Plan, Aetna terminated Letvinuck's disability benefits. Suit was filed in Federal Court. After a prior remand because the district court failed to apply the appropriate standard of review, the Ninth Circuit again heard plaintiff's appeal because the district court again ruled for Aetna. This time, the court reversed outright based on Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 962 (9th Cir. 2006) (en banc), Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008), and Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 630-31 (9th Cir. 2009). The court found several errors in Aetna's determination: First, Aetna gave no consideration to a Social Security award. Although the court did not deem that award binding on Aetna, "not distinguishing the SSA's contrary conclusion may indicate a failure to consider relevant evidence." Montour, 588 F.3d at 635. The award was not mentioned at all when benefits were denied and only acknowledged, but never distinguished, when the denial was upheld. Although Aetna told the plaintiff after the appeal was denied that Social Security uses different standards, the court ruled that failure to address it offers support that the plan administrator's denial was arbitrary, an abuse of discretion." Salomaa v. Honda Long Term Disability Plan, F.3d , 2011 WL 2040934, at *11 (9th Cir. 2011).
Second, Aetna failed to adequately communicate to Letvinuck what additional material or information was necessary to perfect her claim as required by ERISA according to Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 870 (9th Cir. 2008). Aetna never told the plaintiff what was missing at a time when she could have obtained and submitted such documentation. Although Aetna left a voice mail with her treating doctor seeking "clinically objective findings," that was not enough according to Saffon, 522 F.3d at 873 (communicating with a doctor rather than the Plan participant is not meaningful dialogue). Aetna also denied benefits without examining her. As Montour held, a "pure paper" review of a Plan participant's claim "raises questions about the thoroughness and accuracy of the benefits determination." Because Aetna failed to engage in "a meaningful dialogue" with the claimant, its decision was deficient.
For those reasons, Aetna's decision was viewed "with a high level of skepticism" which caused the court to conclude that Aetna abused its discretion in denying benefits.
The court thus held Aetna based its denial of benefits on the absence of specific medical evidence - evidence that Aetna did not tell Letvinuck she should obtain and send to Aetna to perfect her claim. Aetna did not meaningfully explain why it disagreed with the SSA's award of disability benefits, and only attempted to do so when Letvinuck called Aetna after it had already denied her appeal. Therefore, we reverse the district court's judgment in favor of Aetna and remand to the district court with instructions to direct an award of benefits.
Although this ruling is unpublished and therefore non-precedential, it is still extremely instructive. The two key issues raised by the court (failure to distinguish Social Security and failure to inform the claimant what evidence is needed), along with the sub-issue – the skepticism raised by a pure paper review and lack of examination – are major points to keep in mind as a checklist in future litigation.