One of the most frequently cited complaints about Aetna’s disability claims process is the difficulty claimants face when trying to contact company representatives. Newfield Law Group is often contacted by claimants who are ready to give up after weeks of trying and failing to get through to Aetna representatives. The lack of responsiveness and long wait times for answers isn’t just frustrating – it can cause people to miss deadlines for fighting for their claim. This may be due to Aetna coverage being part of Hartford Insurance claims process, once Hartford Insurance made the acquisition of this block of business.
While other insurers aren’t stellar about communicating with claimants, Aetna’s process feels more challenging and more difficult to navigate.
When seeking to apply for long-term disability (LTD) benefits from Aetna, it is essential to understand the intricacies of the process. The application for disability benefits may seem straightforward on the surface. Log into Aetna’s claims portal, fill in the information as requested, and expect that your claim, since it’s entirely legitimate, will be taken care of.
But this is not how things work. The Aetna long term disability insurance claim process is filled with legal, medical, and procedural challenges that can derail an otherwise legitimate claim. We believe this is a deliberate way of winnowing out a certain number of claimants who don’t have the wherewithal to navigate obstacles and simply give up.
Having an experienced long term disability insurance attorney like Jason Newfield on your side to protect your claim is the best way to address dealing with Aetna or any of the disability insurance companies. They are not looking out for your interests, in fact, we believe they are seeking any number of ways to limit their claims exposure.
The more you know about the disability insurance claims process at Aetna, the better decision you can make about how to handle your claim – to try and do it yourself or to retain Disability Attorney Jason Newfield to protect yourself.
Eligibility Requirements: Understanding Aetna’s Criteria
Before applying for LTD benefits, it’s essential to familiarize yourself with Aetna’s eligibility criteria. Aetna’s long-term disability policies vary, but the general requirements typically include:
- Definition of Disability: In most cases, Aetna defines disability as the inability to perform the essential duties of your “own occupation” during the first 24 months of benefits, followed by a transition to being unable to perform “any occupation” for which you are reasonably qualified after 24 months. This distinction is crucial, as it impacts the claim’s duration and the level of scrutiny Aetna applies to the medical evidence.
- Active Employment Requirement: Aetna generally requires that the claimant be actively employed or under the care of a physician for a certain period before they apply for benefits. If you were not working for a period due to illness or injury prior to filing, Aetna may require additional documentation to confirm the continuity of the disability.
- Time Limits for Filing: Aetna’s policies typically require claimants to submit their claim within a specific time frame following their inability to work. If you fail to submit your claim on time, you may lose the right to file a claim.
The Role of Medical Evidence in Aetna Disability Claims
Aetna is known for being meticulous when evaluating medical evidence, and we work closely with our clients to ensure that the proper documentation is provided.
Medical Records: Aetna reviews medical records with a microscope to determine the severity and impact of their condition and look for reasons to deny a claim. Your records must demonstrate a clear, ongoing disability and support the claim that you are unable to work. But even if your records are complete, up-to-date, and accurately reflect your condition, they may not be enough. Here’s what you can expect:
Independent Medical Exams (IMEs): Aetna may request an Independent Medical Exam (IME) as part of the review process. These exams are conducted by doctors chosen by Aetna, paid by and with the intent to undermine the claim. While IMEs are standard, they are used by insurers to challenge the credibility of a claim, so it is critical to be prepared for this possibility and ensure you don’t go to the exam without a witness and without being prepared.
The doctor at an IME is not your doctor, neither are they a friendly professional. Their paycheck comes from the insurance company and their bias has been recognized in many court cases. Jason Newfield works closely with clients to prepare them for IMEs to ensure they don’t fall into any of the traps set by the insurance company while conducting an IME.
Functional Capacity Evaluations (FCEs): In certain cases, Aetna may request a Functional Capacity Evaluation to assess a claimant’s ability to perform the physical demands of their job. We have published many articles about the dangers presented by the FCE to the claimant and to their claim.
The FCE is often conducted by a physical therapist who may not be familiar with the particular injury or illness of a claimant. The test seeks to determine maximum effort in physical tasks, but if you have a bad shoulder injury, the last thing you should be doing is trying to comply with the request of the PT. We caution clients against attending FCEs without being properly prepared. Also, some disability insurance policies do not require claimants to undergo FCEs – in those cases we defend our client’s right to refuse this potentially dangerous test.
Claimant’s Employment History and Job Description
Understanding your employment history and the specifics of your job is another critical aspect of preparing a disability claim. Aetna will likely request detailed information about the claimant’s occupation, including:
- Job Description: An accurate and up-to-date detailed job description, including the physical, mental, and emotional demands of the position. A comprehensive occupational evaluation will assist in determining whether the claimant is truly unable to perform the essential duties of their occupation.
- Earnings and Benefits: Aetna will assess your earnings, including salary and any additional benefits such as bonuses or commissions. Providing clear documentation of earnings can help avoid discrepancies that might arise later in the claims process.
- Workplace Adjustments: If you have made accommodations or adjustments to your work environment due to your condition, this should be carefully documented. Aetna will want to know whether you attempted to work with your condition and what accommodations were made before filing the claim.
Heavy Reliance on Medical Reviews and IMEs
Aetna is notorious for its reliance on Independent Medical Examinations (IMEs) and internal medical reviews conducted by doctors or medical professionals hired by the company. While these are standard procedures in many disability claims, Aetna is particularly aggressive in scheduling and utilizing these examinations. Often, these IMEs are conducted by doctors who are skeptical about the severity of the claimant’s condition or who have a reputation for downplaying certain medical conditions.
Newfield Law Group knows the different doctors used by Aetna and works to protect claimants who are asked to undergo IMEs with them.
When a Newfield Law Group client is asked to go to an IME, we seek to find out if the doctor knows anything about our client’s condition. We have seen many instances over the decades of people with complicated illnesses who are told to have an IME by a physician who has absolutely no experience of the particular illness. It’s like having a brain tumor and being sent to see a podiatrist. Nothing good will come of it.
This put claimants at a serious disadvantage and leads to conflicting opinions about your disability.
Increased Documentation Requirements
Aetna is well-known for requesting extensive documentation from claimants. This includes everything from detailed job descriptions to numerous medical records, Functional Capacity Evaluations (FCEs), and even witness statements about how the disability impacts your daily life. While many insurance companies require similar documentation, Aetna has a reputation for overburdening claimants, which can delay the claims process or even lead to denial if something is overlooked.
Newfield Law Group ensures that Aetna receives all required documents within their tight deadlines. We expect Aetna to try and trip up the claim with a high level of scrutiny, combined with frequent follow-up requests for additional documents. Aetna’s goal of creating an overly complex web of requirements to navigate is nothing new to us.
Aetna’s Aggressive Denial and Termination Practices
Aetna has a well-deserved reputation for aggressively denying claims and terminating benefits, even in cases where the claimant’s medical records and supporting evidence strongly suggest they are disabled. We have known of many cases where Aetna terminated benefits prematurely by insisting that claimants have “recovered” or are capable of returning to work, even if this is not supported by their treating physicians. Many claimants experience their benefits being cut off after the initial two-year period, as Aetna’s definition of disability shifts from “own occupation” to “any occupation.”
For Aetna, this “own occ” to “any occ” transitional period is an inflection point for benefit reductions or denials, making it harder for claimants to continue receiving benefits over the long term.
Appeals Process: Preparing for the Worst-Case Scenario
Even when a claim is fully supported by medical evidence, Aetna may deny the claim for various reasons. In such cases, understanding the appeals process is essential.
- Initial Denial Reasons: Aetna’s initial denials often cite insufficient medical evidence, lack of compliance with policy definitions, or failure to meet certain eligibility criteria.
- The Appeal Process: If the initial claim is denied, Aetna typically allows claimants to submit an appeal. Trying to submit an appeal on your own when your financial future is at stake is risky.
- Legal Strategies in Appeals: If the appeals process fails, litigation is the last resort. Therefore, an appeal is actually preparation for litigation. We cannot overemphasize the importance of preparing an appeal with an eye to litigation. If the case escalates, the documents must be ready to be challenged in court.
Fighting back when long term disability claims have been denied requires an experienced long term disability attorney who knows the tactics used by insurance companies to deny claims.
If you have questions, call Jason Newfield to arrange for a free consultation and review of your case.
