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Los Angeles and Orange County Disability Insurance and ERISA Claim Attorneys Fight Aetna Claim Denials

At McKennon Law Group PC, we represent a wide variety of policyholders and claimants, including those with bad faith claims, long-term disability, short-term disability, life insurance, health insurance, ERISA or employee benefits claims, long-term care insurance and more.  We aggressively fight wrongful and bad faith claim denials from life and disability insurers like Aetna. Several of our lawyers, including Robert J. McKennon, previously represented insurance companies in life, health and disability claim denial litigation for many years, which is why we understand insurers like Aetna and is one of the reasons we are so successful in pursuit of insurance benefits for our clients.  In our practice, we see many clients who come to us with denied disability insurance claims from Aetna, who is one of the biggest disability insurers in the United States.  We find that most of the time, we are able to force Aetna to place our clients back on claim and pay all benefits owing them that are past-due and owing in the future.

Aetna was founded in 1853 in Hartford, and was organized to sell life insurance.  In 1899, Aetna entered the health insurance business and shortly thereafter, Aetna began offering liability coverage.  By 1907, Aetna began offering automobile coverage and developing related lines, such as collision and damage.  In 1913, Aetna formed a department to sell group life insurance and six years later, began offering group disability policies.  The Aetna we know today is one of the largest companies in the insurance industry.  In 2016, Aetna counted more than $63 billion in revenues.  Presently, Forbes lists Aetna at within the top 50 companies on the Fortune 500.

In 2016, California Insurance Commissioner Formally Recommends that the U.S. Department of Justice Block Merger of Aetna and Humana

California plays a unique role regarding the regulation of insurance in the U.S., in part, because the California insurance market is the largest in the country.  In fact, insurance companies collect approximately $259 billion in premiums annually and health insurers and managed care plans collect $122.9 billion in California alone.  In a twenty-four-page letter to the attorney general and principal deputy assistant attorney general, California Insurance Commissioner Dave Jones expressed serious concern regarding Aetna’s proposed acquisition of Humana and the impact that would have on competition in the California health insurance market.  The Insurance Commissioner was primarily concerned with the impact this would have on the medical insurance market given the relative dominance of the companies involved.  Aetna and Humana would combine the third and fifth largest health insurers according to market value.  (The letter also notes that, at the time, Anthem and Cigna were also proposing a merger, which were the second and the fourth largest health insurers by market value.)

The California Insurance Commissioner held several public hearings on the proposed merger.  Over time, he developed an extensive public record with testimony, public comment, studies and other such similar information regarding the proposed merger of Aetna and Humana.  Ultimately, he determined that the combined market power of the two companies would have a substantial anticompetitive effect on several regions, including California.  Giving a single entity that much combined power would give it the authority to increase the cost of premiums, decrease the quality of care and reduce access to insurance products.

The U.S. Department of Justice listened and sued to stop the merger of the two behemoths of insurance, along with the attorneys general from eight states and one from the District of Columbia.  In recent news, it appears that the lawsuit was successful.  On January 23, 2017, a federal judge blocked the deal from moving forward.  In so doing, the court acknowledged the potential for harm to the insureds.  In February 2017, Aetna’s chief executive officer, Mark Bertolini, made an official statement halting the merger.  According to CEO Bertolini, pursuing the merger between Aetna and Humana in “the current environment makes it too challenging to continue pursuing the action.”

How does Aetna Deny Life, Medical and Disability Insurance Claims?

Aetna may deny a claim for benefits for a variety of reasons.  While this list is by no means exhaustive, we frequently see denials that use variations on the assertions below.

  • The medical evidence does not support the life, medical or disability claim
  • The claimant did not provide adequate medical support for the life, medical or disability claim
  • The claimant did not provide documentation or proof of loss evidence in a timely manner
  • The medical condition, illness, injury or sickness which is the subject of the claim is a pre-existing condition and thus excluded from coverage
  • Because the insurance application allegedly contained materially false statements, the policy will be rescinded
  • Surveillance of social media, in-person or some other form suggests that the claimant is not totally disabled
  • The claimant’s policy has lapsed for failure to pay premiums
  • An exclusion in the life, medical or disability policy precludes coverage of the claim

What Should Disability, Medical or Life Insurance Claimants Look for When Aetna Denies a Claim?

  • Did they conduct a thorough and adequate investigation of the claim?
  • Did your denial letter rely on the opinion of a clinical reviewer or a peer review physician you have never heard of before and who has never treated you in person?
  • Did the insurer rely on this opinion over the opinion of your primary treating physician?
  • Did the insurer misread, misinterpret or completely ignore pertinent medical records?
  • Did the company deny your claim without conducting an in-person examination?
  • Did the insurer refer to your complaints of pain, fatigue or other medical evidence as “subjective” and deny your claim because there is not objective evidence of the condition? Frequently, we see this issue with mental disorders, autoimmune disorders, fibromyalgia, and chronic fatigue syndrome.
  • Did the insurer deny your claim based on surveillance or social media evidence taken entirely out of context?
  • Did the insurer require that you apply for state or federal disability benefits, but then ignore their decision when they approved your claim? For example, are you receiving Social Security Disability Insurance benefits, but were denied by your employer benefit plan?
  • Did the insurer adequately address the reasons why Social Security Disability Insurance benefits were paid and adequately contrast the decision with its own decision?

If you feel you have a wrongfully denied claim for disability, medical, life or other insurance involving Aetna, the McKennon Law Group PC will aggressively fight for your insurance benefits 

Having an aggressive and experienced disability, health and life insurance attorney is the most important decision you can make for the success of your insurance claim.  If your claim for health, life, accidental death or dismemberment, short-term disability or long-term disability insurance has been wrongfully denied or suddenly terminated, fill out a free consultation form or call (949) 387-9595 to schedule a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and non-ERISA, bad faith insurance claims.