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Cigna Approves Disability Claim Following Multiple Denials

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

Prior to contacting Dell & Schaefer our client filed a claim for Short Term Disability benefits with Cigna under her employer’s group disability insurance policy due to Chronic Pain stemming from multiple degenerative conditions of her cervical and lumbar spine. Cigna initially approved her claim for disability benefits after review of her medical records, which included positive findings of impairment on examination, objective medical tests such as MRIs and the supportive opinion of her doctors. Despite initially approving her claim and unwavering support from her doctors, Cigna terminated her short term disability claim with just three weeks of benefits remaining after Cigna had her file reviewed by two internal medical professionals, who opined that she would be able to perform the duties of her Sedentary pre-disability occupation. In response to the denial our client quickly filed her first appeal on her own providing argument as to the denial but no new substantive medical information in support of her disability. Having fallen into Cigna’s trap her appeal was met by yet another denial from Cigna after it once again relied on additional paper file reviews performed by its doctors.

After her second denial of benefits, and still out of work due to her medical conditions she contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup. Attorney Jessup advised that it would be in her best interest to file a voluntary level appeal in order to provide additional objective evidence of disability, with specific attention to having a Functional Capacity Evaluation performed to address Cigna’s position that our client had a full level of Sedentary physical ability. The FCE indicated that our client did not have the ability to work in a full time Sedentary capacity, but Attorney Jessup knew that Cigna would challenge the results of the FCE as the testing was performed almost ten months after the initial denial of benefits. Armed with the FCE results Attorney Jessup set about correlating the current FCE findings with the previously provided medical information in support of disability to draw a nexus and argue that the current testing results would have been indicative of our client’s restrictions and limitations at the time of the initial denial of short term disability benefits. Despite having the favorable FCE, multiple MRIs, X-Rays and EMG/Nerve conduction studies and the support of her doctors, Cigna, true to form, had her claim reviewed again by doctors who ignored the plethora of medical evidence and again rubber stamped the two initial denials.

The Long Term Disability Application

Faced with a final denial of her administrative appeals and her only remaining recourse for short term disability benefits being a civil lawsuit under ERISA, Attorney Jessup suggested that a separate application be made for long term disability benefits. In advising our client to file her long term disability claim Attorney Jessup knew that it would not only open the door for additional administrative appeals but it would also allow our client to bring a lawsuit for both short and long term disability benefits should Cigna continue to deny her claim. However, the advice to file for long term disability benefits despite the denial of the remainder of the short term disability period was predicated on the fact that Attorney Jessup has successfully won long term disability benefits with Cigna despite short term disability benefits having been denied.

In filing our client’s claim for long term disability benefits Attorney Jessup submitted the appeals previously filed on our client’s behalf along with updated claim forms and attending physician’s statements from her doctors. Faced with the information presented, and despite its own multiple prior denials of short term disability benefits, Cigna’s long term department approved our client’s claim for benefits and in doing so sent a check for a over a year’s worth of back benefits owed. Armed with the long term disability award letter Attorney Jessup contacted the short term disability department and demanded immediate payment of the remaining three weeks of short term disability benefits or a lawsuit would be filed. Without hesitation Cigna forwarded the remaining short term disability benefits owed to our client.

Claims Handling

Although our client’s claim has been reinstated and all back benefits owed have been paid she knows that as long as Cigna is providing benefits her claim will always be under the scrutiny that Cigna has already displayed. Attorney Jessup continues to represent our client and despite the fact her long term disability claim is still under the “own occupation” definition of disability, Attorney Jessup is already preparing her claim for “any occupation” review still to come.