Aetna Sued After Basing Claim Denial on Allegedly False Conclusion

A plaintiff filed suit last Friday in the District of New Jersey against his insurance company, Aetna Inc. and Aetna Life Insurance Company. The action, which was filed under the Employee Retirement Income Security Act of 1974 (ERISA), comes after repeated denials by the defendant to cover the plaintiff’s medical expenses, which he claims he is entitled to under his insurance policy with Aetna.

After noticing the presence of a rash covering his whole body, the plaintiff sought out medical attention for what he presumed to be eczema. Following two biopsies, he was diagnosed with stage III CTCL-MF, or Mycosis Fungoides. Mycocis Fungoides (MF) is “a rare form of blood cancer also called cutaneous T-cell lymphoma.” The symptoms of Mycosis Fungoides include weight loss, redness, itching, and an overall burning sensation on one’s skin. MF has a median survival rate of four to six years. A recent article detailed that a five-year survival rate for a patient with this type of cancer is only 16%.

Following his diagnosis, the plaintiff’s doctor placed him on a chemotherapy regimen, which he is still on. The plaintiff has an insurance policy with the defendant called the Critical Illness Plus with Cancer with Recurrence, a policy to which both he and his employer have paid the necessary premiums. The defendant’s policy provides a fixed dollar benefit for covered expenses up to $40,000. The complaint specifies that “the policy makes clear that an insured…with this type of invasive cancer has coverage under the plan.”

Aetna provides that they will cover any cancer diagnosed as invasive, which they define as “the presence of malignant cells or a tumor characterized by the uncontrolled and abnormal growth and spread of the invasive cells.” The complaint argues that the plaintiff’s condition clearly meets this definition outlined by the defendant, and even goes farther since his cancer has spread.

Despite “being covered under the Policy,” the plaintiff’s claim for coverage was denied Aetna, who reasoned that “the skin cancer benefit is not payable based on our review of the information provided,” and that his diagnosis “did not meet the criteria and/or definition stated in the Plan certification.” Although the plaintiff’s cancer is causing skin problems, he does not have skin cancer, Aetna allegedly concluded.

He appealed their denial on the grounds that Aetna had “erroneously” come to this conclusion, according to the complaint; Aetna denied the appeal They supplemented the denial by informing the insured that he had exhausted any means of internal appeals with Aetna and would have to pursue further appeals in Court.

The complaint details that the defendant has been provided with the plaintiff’s official diagnosis of MF, not skin cancer, “on at least two occasions.” It further cites that the defendant violated ERISA when they denied the plaintiff his entitled benefits. The plaintiff is seeking punitive damages, interest, costs of the suit, reasonable attorney’s fees, equitable and declaratory relief, and any other relief deemed equitable by the court.

The insured is represented by Mandelbaum Barrett in the litigation.