Daily Document Update: HR Compliance Library, ¶46,366, Aetna’s denial of LTD benefits to melanoma patient overturned — FEDERAL NEWS, (Sept. 19, 2019)

摘要

A store manager who was diagnosed with malignant melanoma was entitled to benefits under his employersponsoredlong-term disability (LTD) insurance plan, the U.S. Court of Appeals for the First Circuit held, findingthat Aetna Life Insurance Company’s denial of benefits based on the plan’s exclusion for preexisting conditionswas arbitrary and capricious. The evidence showed that Aetna’s structural conflict of interest played a role inits handling of the insured’s claim and that the company violated ERISA regulations by using new or additionalrationales for its denial without affording the insured an opportunity to respond. According to the court, althoughthe insured had visited his physician for a skin lesion prior to the effective date of his coverage, the preexistingconditions exclusion did not apply because the physician neither diagnosed nor treated melanoma at that time.