For everything there is a season . . . including, it turns out, a season for Aetna Life Insurance Company to deny Boeing workers’ disability claims.
Boeing formerly used Aetna to manage its short-term disability claims. It quit doing so earlier this year when it retained Aon Hewitt Absence Management for that purpose. Short-term disability claims that Aetna already had in its hopper – at least those I have seen in the past months – follow a similar pattern. It goes like this: a long-term Boeing employee becomes too ill to work and applies for disability benefits. Aetna denies the application, and, as ERISA requires, advises the employee that he or she can appeal the denial. The employee submits an appeal, including unequivocal statements and records from treating doctors demonstrating disability. Aetna assigns an “Appeal Specialist” to the claim.
The “Appeal Specialist” sends a letter to the employee, opening with the cheerful words “Good News!” The letter states that Aetna received the appeal (hence the “good news” – apparently institutional joy that a piece of certified mail has arrived), and that a decision will be made in 45 days. Just before that 45-day period ends, the “Appeal Specialist” sends another letter, stating that Aetna can’t manage to complete its processing of the appeal, and will require another 45 days.
In fact, the federal regulation that allows an ERISA insurer like Aetna an additional 45 days to determine an appeal requires the insurer to describe the “special circumstances” that require such an extension. Aetna’s letters typically state only that its need to perform a “medical review” requires an extra 45 days. That hardly sounds like special circumstances –any sensible assessment of a person’s disability status will require some medical review . . .
Aetna then orders up a “peer review” – a review of selected papers from its claim file by a purportedly “independent” consultant. The consultant then writes a report concluding the Boeing employee “has no functional limitations,” and the “Appeal Specialist” writes the employee a letter denying the appeal.
Those letters conclude with the bold type statement, “We’re here to help you.”
I’m not so sure about that one.