In the case of Darren Cohen v. Aetna Life Insurance Company (Aetna), Plaintiff Darren Cohen was employed by a computer data storage technology company, STEC, Inc. His occupation was that of a Computer Systems Engineer, which required him to sit at his computer for 6-8 hours every day.

In 2008, Plaintiff suffered a traumatic brain injury (TBI) and spinal cord compression in a Go-Kart accident that occurred at a work-sponsored event. After being off work for 18 months, he tried returning to work part-time but was unable to continue. Aetna approved his clam for long term disability (LTD) benefits for 24 months finding that he was unable to perform the duties of his own occupation.

After 24 months, the definition of disability changed, and Plaintiff had to prove he was unable to perform the duties of “any reasonable job.” The definition of a reasonable job was “any gainful activity for which you are; or may reasonably become, fitted by education; training; or experience.” After initially finding Plaintiff was no longer disabled, in response to Plaintiff’s appeal, Aetna reinstated benefits.

Ultimately, Plaintiff received LTD benefits beginning in February 2009 until July 25, 2018. Aetna periodically reviewed his medical file. On several occasions, Aetna conducted video surveillance of plaintiff. After reviewing surveillance conducted in July and August 2015, Aetna concluded Plaintiff was still disabled. A vocational consultant also reported it would be difficult for Plaintiff to find a job.

Surveillance conducted in June 2017 changed Aetna’s view. It decided plaintiff was “very active” and ordered him to undergo an independent medical exam (IME).

The IME was conducted in February 2018. The examining doctor concluded that Plaintiff could return to work with restrictions of frequent breaks and an ergonomic workstation.

Aetna commissioned one more doctor to review the medical records. This time, the reviewer concluded that Plaintiff could return to work with no restrictions.

Based on the video surveillance, IME, and paper review, Aetna terminated Plaintiff’s LTD benefits effective July 25, 2018. Plaintiff’ filed an administrative appeal where he submitted updated medical records, current physician statements, and his own vocational analysis performed February 2019. All supported his claim that he was unable to work in any reasonable occupation.

Aetna responded by having two more doctors conduct peer reviews of Plaintiff medical records. When one reviewer disagreed with Aetna’s desired conclusion, Aetna sent it back and asked the doctor to change his report. The doctor did. This time, the doctor said Plaintiff could perform a full-time job with just some restrictions. Aetna then upheld its decision to terminate benefits.

Having exhausted his administrative remedies, Plaintiff filed this ERISA lawsuit in the U.S. District Court for the Central District of California. The California Court ruled in favor of Plaintiff, finding that the work restrictions verified by Plaintiff’s physicians and at least one of Aetna’s physicians made it impossible, according to the policy definition of disability, for Plaintiff to work at “any gainful activity for which [he is]; or may reasonably become, fitted by education; training; or experience.”

Plaintiff’s Medical Evidence Proved by a Preponderance of the Evidence That He Was Disabled According to the Policy’s Definition of Disability

The Court reviewed the comprehensive administrative record which included reams of medical evidence supporting Plaintiff’s claim for disability as well as three separate video surveillance records from three different years.

The Court noted that Aetna’s physician that conducted the IME spent only eight minutes examining Plaintiff before concluding all he needed was an ergonomic workstation with frequent breaks. That doctor did not even review medical reports the Court found relevant. The two reviewing physician reports submitted by Aetna, one of which was changed at Aetna’s request, were not enough to overcome the evidence submitted by Plaintiff.

The Court concluded, “Plaintiff has provided enough evidence to rebut those opinions through doctors’ visits, reports, and recommendations from 2008 and as recent as January 2019. This is enough to meet [Plaintiff’s] burden.”

Court Finds Video Surveillance Did Not Contradict the Medical Evidence and Did Not Support Aetna’s Termination of Benefits

The Court’s conclusion of the significance of the June 2017 surveillance video was different than Aetna’s. Aetna argued it showed Plaintiff performing activities that “he should avoid.” The Court noted:

“having reviewed the videos, [the Court] finds that they largely show Cohen performing routine activities such as walking, driving, and sitting/eating. At one point, one video clip showed Cohen performing a light jog while wearing a backpack. The Court will consider the video evidence alongside all other evidence in its final determination of whether Cohen has met his burden in this case. However, the Court generally notes that there is a difference between performing routine activities for short periods of time and working 8 hours a day, 5 days a week performing repetitive tasks or sitting/standing for prolonged periods of time.”

Ultimately, the Court concluded that the video did not rebut the medical evidence. The activity of Plaintiff on the video showed him performing “routine acts of life…even the recording of [Plaintiff’s] light jog does not persuade the Court that his medically reasonable restrictions are not supported by the record.”

The Court’s Final Order

The Court’s final order stated: “After reviewing the administrative record and the parties extensive briefing on this matter, the Court concludes that Aetna improperly denied LTD benefits since July 2018. Further, Cohen has proven he is entitled to those benefits by a preponderance of the evidence.”

Contact Dell & Schaefer for a Free Consultation

This case was not handled by our law firm, but we believe it can be instructive to those who find their benefits terminated after receiving them for several years with no change in their medical conditions. If you have had benefits terminated or have any problem with your claim for short-term disability (STD) or LTD benefits, contact one of our disability attorneys at Dell & Schaefer. We will review your policy and provide a free consultation to discuss how we can help you.