Aetna Reverses LTD Termination

I represent a former marketing sales manager with narcolepsy and Chronic Fatigue Syndrome (“CFS”) whose LTD benefits were terminated after she attended an independent medical exam (“IME”). Disability insurers usually ask claimants to attend an IME when all of the evidence submitted supports entitlement to benefits. 

Insurers pay for an IME in order to manufacture contradictory evidence when all the evidence shows a claimant cannot work. When an insurer makes the commitment to incur the expense of an IME it normally means that it has already decided to terminate the claim. In the absence of evidence showing that the claimant’s medical condition has improved, the insurer knows that it must pay an IME to support the termination, which typically involves the IME doctor claiming that the objective evidence does not support the treating experts’ restrictions and limitations. 

Insurers will claim that an IME is needed to clarify the medical restrictions and limitations even where the treating experts provide very detailed functionality assessments. The insurers will simply fail to provide any reason for requesting the IME, which proves that there is no legitimate reason for the IME, other than to create a written report to support the predetermined financial incentive to terminate the claim. 

IMEs are not “independent” in the sense of unbiased, or fair and equitable. The purpose of an insurer’s IME is to have the claimant examined by a doctor who is in the pocket of the insurance industry for the purpose of agreeing with all internally provided medical reviews supporting non-payment of claims. Insurers argue that “independent” means an examination by a physician who never examined the claimant. Notably, a CIGNA managing agent recently testified that an IME is only independent if hired by CIGNA – and that doctors hired by a plaintiff who never examined the plaintiff are not independent. 

Because insurers paying a lot of money for an IME, they rely solely on the IME, and give no consideration to the claimant’s treatment records and medical restrictions and limitations from the treating physicians that preclude work. If that were not the case, then insurers would have to pay disability benefits when the evidence supports continued disability without requiring an IME. 

The primary problem with Aetna’s termination was that it ignored all of the evidence in favor of the IME. Besides the fact that Aetna’s own in house doctor said that the IME should be performed by a sleep specialist, the IME was performed by a neurologist, with no narcolepsy or CFS experience, which focused on the claimant’s physical capabilities and memory, but disregarded the narcolepsy and CFS. Significantly, the IME stated the claimant could work in an occupation that was “well supervised.” I obtained a detailed vocational evaluation which stated that all of the occupations Aetna said the claimant could do required the ability to work independently, complete deadlines and handle many tasks at one time, and none of those occupations were well supervised. Confronted with concrete evidence undermining the premise for the termination, Aetna reversed its decision.