ERISA-Ninth Circuit Rules That Aetna’s Denial Of A Claim For Disability Benefits Was An Abuse Of Discretion

In Letvinuck v. Aetna Life Insurance Company, No. 10-55018 (9th Cir. 2011) (an unpublished opinion), the plaintiff had brought suit under ERISA when the plan of her employer (the “Plan”) denied her claim for short-term and long-term disability benefits. Defendant Aetna Life Insurance Company (“Aetna”) was the plan administrator and insurer under the employer’s plan. Consequently, it was Aetna who decided to deny the plaintiff’s claim on the plan’s behalf.

In reviewing Aetna’s decision to deny the claim, the Court applied a deferential review, since the Plan gave Aetna discretion to decide benefit claims. However, the Court found that, in deciding to deny the plaintiff’s claim for disability benefits, Aetna had abused its discretion. The Court cited the following reasons for this finding:

(1) Aetna gave no weight to the Social Security Administration’s decision that the plaintiff was disabled, nor did it provide an explanation as to why it gave no weight.

(2) Aetna failed to adequately explain to the plaintiff what additional material or information was needed to perfect her claim, and to do so in a manner calculated to be understood by her. Aetna based its denial of the plaintiff’s claim on the absence of specific medical evidence — evidence that Aetna did not tell the plaintiff she should obtain and send to Aetna to perfect her claim.

Finding that Aetna abused its discretion, the Court overturned Aetna’s denial of the plaintiff’s claim for disability benefits, as well as the district court’s decision which had upheld the denial. The Court remanded the case back to the district court with instructions to award the plaintiff her benefits.

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