A South Carolina disability attorney recently filed a lawsuit at the District Court for the District Of South Carolina against the Aetna Life Insurance Company (Aetna Life) for violations under the Employee Retirement Income Security Act of 1974 (ERISA). In Janice Cole vs. Aetna Life Insurance Company, Community Health Systems, Inc. d/b/a Springs Memorial Hospital; Springs Health Care, Inc.; and The Community Health System Long Term Disability Group Plan, the plaintiff Janice Cole claimed that Aetna Life wrongfully denied the plaintiff her claim for disability benefits under the Springs Memorial Hospital’s employee welfare benefit plan and is seeking actual disability benefits, attorney’s fees & costs, pre-judgment interest, statutory penalties and other equitable remedies through the Court.

The Alleged Facts in the Lawsuit: South Carolina Disability Attorney sues Aetna Life for violations under ERISA

The plaintiff Janice Cole was employed at the Springs Memorial Hospital as a registered nurse. She was a participant in the Hospital’s employee welfare benefit plan called The Community Health System Long-Term Disability Group Plan (LTD Plan) and which was insured by Aetna Life. Aetna Life also acted as the Claims Administrator for the LTD Plan while Springs Memorial was the plan administrator of the LTD plan.

The plaintiff was and is suffering from fibromyalgia, chronic fatigue syndrome, obstructive sleep apnea, neuralgia, etc. On May 6th 2006, due to her worsening symptoms as a result of her medical conditions, the plaintiff became physically unable to perform the duties required of her as a registered nurse and resigned her position as nurse manager.

The plaintiff filed a disability application for long term disability (LTD) benefits and was initially denied on June 4, 2008. Later, it came to light that Aetna Life had “lost” the plaintiff’s claims file. The plaintiff also tried to work part time at a local nursing care facility but had to quit when her job performance was not satisfactory due to her suffering from fibromyalgia, chronic fatigue syndrome, chronic pain, recurrent herpetic eruption with chronic post-herpetic neuralgia, obstructive sleep apnea, and hypertension. This incident marked the first time in the plaintiff’s entire career as a health care worker that her job performance was below par.

Having been denied her claim for long term disability benefits following submission of her disability application, the plaintiff submitted an appeal to Aetna Life and was denied by Aetna Life on March 2nd 2009; more than ten months after Aetna Life lost the plaintiff’s original claims file.

On August 3rd 2009, the plaintiff, through her South Carolina disability attorney, contacted Aetna requesting a reconsideration of Aetna’s decision to deny the plaintiff her claim for LTD benefits on the grounds that there was “a significant amount of evidence which never got to Aetna and which is favorable to” the plaintiff’s claim for LTD benefits. Having received no response from Aetna Life, the plaintiff’s disability attorney tried to telephone Aetna Life’s designated representative on November 18th 2009 followed by a letter on November 19th 2009. According to the lawsuit, despite numerous attempts to contact the Aetna Life’s representative, no response was forthcoming.

On May 5th 2010 the plaintiff’s disability attorney wrote a second appeal to Aetna Life’s designated representative and submitted seven exhibits including a Notice of Social Security Disability Award and a medical statement from Dr. Michael Kimbrell dated December 17, 2008 to support the plaintiff’s claim for LTD benefits. At the same time, the plaintiff’s disability attorney also requested Aetna Life to provide a complete Administrative Record concerning the plaintiff’s claim.

On June 3rd 2010, the plaintiff was informed that her prior designated Aetna Life’s representative no longer worked with Aetna Life. Instead another Aetna Life’s representative, Donna Kirkby took over the handling of the plaintiff’s case. According to the lawsuit, the Aetna Life’s representative, Donna Kirkby, claimed that she had tried to contact the plaintiff’s disability attorney but had not received a call back. The plaintiff alleged that this new representative, like her predecessor, had failed to leave a phone extension. According to the lawsuit, the Aetna Life’s representative, Donna Kirkby, refused to further review the plaintiff’s final appeal for LTD benefits payments.

The plaintiff alleged that at no time, did Aetna Life ever provide the requested Administrative Record or Plan Documents. In addition, Aetna Life also denied death benefits with waiver of premium to the plaintiff. In the lawsuit, the plaintiff alleged that as a result of Aetna Life’s actions, she had depleted her financial resources and had to file for bankruptcy. She also alleged that she is on the brink of losing her house in foreclosure for the same reason despite her attempts to seek loan modification. The plaintiff’s lender had denied her a modification because she lacked income to pay her mortgage and her lack of income is directly related to Aetna Life’s refusal to pay her monthly disability benefits.

Relief Sought In the Lawsuit by the Plaintiff

Having exhausted all her administrative remedies, the plaintiff is asking the Court to use its equitable power to restore the plaintiff to the position she would have been in if Aetna Life had not wrongfully denied her benefits. As such, the plaintiff is seeking the following relief:

  • An order declaring the existence of LTD and life benefits with a waiver of premiums under the plan.
  • An order requiring Aetna Life to provide said benefits under the LTD Plan.
  • An order declaring the plaintiff to be entitled to future benefits.
  • An order granting Plaintiff reasonable attorney’s fees.
  • An award of Prejudgment interest, costs, expenses incurred in connection with the lawsuit pursuant to ERISA, 29 U.S.C. Section1132 (g)(1).
  • Any other equitable relief which the Court deems just and proper.
  • An order declaring the plaintiff to be entitled to future benefits.
  • Enforce the provisions of ERISA’s penalty of One Hundred and Ten Dollars ($110.00) per day for failure to provide the Plan Documents.

Prior to engaging a disability attorney, the plaintiff was unrepresented during the appeal process. This could possibly be one of the reasons why Aetna Life was so “careless” in handling the plaintiff’s original claims file. As a result of the loss of the claim file, the appeal process was further delayed and complicated to the detriment of the plaintiff’s case.