District Court Scolds Aetna for Confusing Claim Files and Suggests Such Disorganization is Evidence Arbitrary and Capricious Decision-Making
If you have ever handled a group disability insurance claim (ERISA or otherwise), you know that navigating the claim file (the large document supposedly comprised of all of the materials the insurer generated, received, or considered in rendering a determination) is by far the most difficult part of the job. This is particularly true if you’re a claimant or a practitioner that does not deal with disability claims on a regular basis. Often, the file is comprised of nearly incomprehensible “claim notes” which is basically insurance-speak for the notes claims adjusters take as they administer/deny your claim. It also contains peer reviews by the insurance company’s doctors and nurses, as well as the medical evidence you submitted to the insurer.
If you’re lucky, the contents will be in some type of order, but often they are not. And, even if the documents are organized, do not count on that order being chronological or even recognizable. Often claim files (which are eventually morphed into the administrative record) are a complete mess and come with absolutely no index or key to help claimants navigate the file from which they must challenge a denial within the relatively short time period for doing so under governing laws. Unfortunately, there is little reprieve for individuals trying to navigate these muddy waters besides hiring an attorney who is skilled in reviewing and analyzing such files.
The United States District Court of the District of Massachusetts recognized this disadvantaged and called one insurer out on the practice. In Young v. Aetna Life Insurance Company, 146 F. Supp. 3d 313 (D. Mass 2015), Aetna denied Young’s claim then presented her and her counsel with a claim file (now, in litigation, referred to as the administrative record) in no discernable order with various duplications and no labels. District Judge Hillman scolded Aetna as follows: