When a senior sales executive at SAP America suffered a fall in late 2016, little did she know that her life would be forever changed. She had worked in her high-executive job at the company for seven years, enjoying a good salary for her hard work. But the fall left her with a diagnosis of post-concussive syndrome and traumatic brain injury.
What happened next is a testament to how the legal system can work on behalf of those who unfairly receive a disability insurance claim denial. Fortunately, disability attorney Alexander Palamara stepped in help facilitate a positive outcome and happy ending for the claimant in this particular case. He tells how the story unfolded and how the multiple layers of an ERISA appealcan work for – or against – those suffering from a long-term disability (LTD).
Picking up the Pieces
The woman tried valiantly to reconstruct her former lifestyle and return to work. However, by early 2017, it was evident she would be forced to discontinue in her position with SAP America. After making a claim for disability insurance benefits through her policy with Aetna, she was pleasantly surprised that Aetna, in good faith, approved her claim. But they did so on their own terms, setting the claim on a slippery slope that would quickly head downhill.
As it turned out, Aetna had actually denied her claim of post-concussive syndrome, according to attorney Alexander Palamara. They instead concluded that she had a psychological and mental health issue that needed to be treated for a short period of time. This set her up for a series of treatments for a supposed mental health disorder rather than her actual brain injury.
When the short-term mental health treatment came to an end, Aetna was able to deny her long-term traumatic brain injury (TBI) claim due to a lack of medical records substantiating that condition. By instead treating her for mental health issues, they denied the more serious condition and stated that her neuropsychological testing was inconsistent.
When the brain-injured claimant found disability insurance attorney Alexander Palamara and the team from Dell & Schaefer law firm, they went into action on her new denied disability claim. They ended up ordering all her medical documentation related to the claim, quickly compiling a list of things that Aetna got wrong.
“First and foremost,” states Palamara, “the neuropsychological testing was not inconsistent at all. In fact, it’s true that she had a significant reduction in processing skills and processing speed.”
She also had compromised functional memory skills, and her neuropsychological evaluation was very supportive of the claim. Her treating physicians corroborated the condition as well. But before drafting a formal appeal to their client’s denied disability claim, the skilled attorneys reached out to an independent physician reviewer.
This credible physician had a background of working for the University of Virginia and serving as a physician for the USA swimming, USA soccer and USA women’s soccer teams. He was also part of the Brain Injury Alliance and uniquely qualified as an expert in the field.
“I knew this expert would be the person to review these documents,” stated Alexander Palamara. “And if this person was supportive of my client’s claim, I knew there was no doubt that Aetna would have to overturn their denial.”
The doctor reviewed all the medical records and conferred at length with the attorneys, who explained the client’s occupational requirements and history. “The doctor came to the conclusion that he would unequivocally support that our client was disabled from her previous occupation,” said Palamara.
The team from Dell & Schafer submitted a timely appeal containing a report from the independent physician reviewer, along with other medical records supporting the client’s claim. They also presented a solid argument that Aetna’s denial decision was not only wrong but was “arbitrary and capricious.”
Within six weeks of filing that appeal, Aetna overturned their denial. The client is now back on claim, receiving benefits to this day. She’ll likely need benefits until the age of 65. But if she is able to return to work at some point, she has the assurance that, should she ever need it again, Dell & Schaefer will do whatever it takes to keep her on claim.
Anyone with a similar issue in which Aetna has denied a long-term disability insurance claim can reach out to Alexander Palamara or another disability insurance attorney at the Dell & Schaefer law firm. The phone call or email contact is totally free, as is the initial consultation. They handle cases and appeals anywhere in the country and will let you know right away if they can help.