UPS Supervisor with Back Pain Awarded Disability Benefits Against Aetna Due to Back Pain

A 50 year old supervisor at UPS sued his long-term disability carrier, Aetna, and was awarded benefits due to insurer’s rejection of the employee’s complaints of pain. The employee started experiencing back pain which was directly to his job duties. Later, he experienced pain in his abdomen and was eventually diagnosed with chronic kidney disease.  The employee’s pain became so severe that he missed approximately one month of work. He returned to work with lighter duties, however, he soon had to leave work again due to the worsening of his condition.

The employee’s doctor placed him on disability, but regardless, Aetna denied his request for coverage.  The employee appealed Aetna’s decision only to have his appeal denied, leaving the employee no alternative but to sue in federal court. A court awarded the employee short-term disability benefits explaining that Aetna had failed to explain to the employee the “type of evidence that would be sufficient to corroborate his subjective complaints of pain.”

After being awarded short-term disability benefits, the employee applied for long-term disability benefits. Again, Aetna denied the employee benefits, basing its decision on the insurance policy’s definition of “disability.” According to the policy’s definition of disability, the employee must be unable to perform material duties “of your own occupation solely because of an illness, injury or pregnancy-related condition and your earnings are 100% or less of your adjusted pre-disability earnings.”

Aetna denied the employee benefits, it argued, because the employee could no longer substantiate his functional impairment.  The employee appealed, arguing he had tried to work but was unable to drive or meet the physical requirements required of his job.  The employee again appealed Aetna’s decision and this time the insurer had a physician review his medical records. Aetna’s reviewing doctor concluded that the employee’s records lacked any studies, lab results, etc., showing a functional impairment. Based on his findings, Aetna denied the appeal and the employee once again took his claim before a federal judge.

After reviewing the evidence, the court ruled in the employee’s favor, awarding him long-term disability benefits. The court took issue with Aetna denying the employee’s disability claim “based on his failure to produce evidence that is simply not available.”  Specifically, Aetna required the employee to prove “subjective pain,” which cannot be diagnosed by an imaging study, but instead relies on the observations and complaints of the person experiencing pain.  Aetna’s decision, the court explained, “was unreasonable and an abuse of discretion.

The court also found that Aetna abused its discretion by not giving sufficient consideration to the doctors who reviewed the case.  Aetna’s doctor, Dr. Lee, failed to identify any evidence contradicting the findings of the employee’s treating doctors who found his complaints of pain to be consistent with his medical condition.  The takeaway from this case is simple, but important. Aetna wrongfully denied the disability claim because it sought “objective medical evidence” for functional impairment.

The case is Smith v. United Parcel Service, Inc., No. 3:20-00454-LRH-CLB, 2022 WL 1271739 (D.Nev. Mar. 24, 2022).