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12 years of disability payments paid, but CIGNA suddenly determines claimant can perform sedentary job

A disability claimant receiving benefits from CIGNA can never let their guard down. CIGNA is constantly evaluating their claims and if they have an opportunity to deny disability benefits then they will do so. This case is an example of a woman that was paid over 12 years, before CIGNA decided to unreasonable pull the plug. Despite a deterioration of this woman’s medical condition, how could CIGNA really expect this woman to return to a 40 hour job?

The plaintiff, by virtue of her employment with Markel, was covered under an employee Long Term Disability Insurance plan issued by CIGNA Insurance Company. During the time that she was employed, the plaintiff was diagnosed with Lyme disease and fibromyalgia which causes her chronic pain, muscle spasms, difficulty sleeping, decreased energy, decreased memory and difficulty walking, standing and sitting.

Due to the severity of her medical conditions, the plaintiff stopped working on July 1998. She was approved by CIGNA to receive long term disability benefits on June 30th 1998 effective from December 30th 1998. In 2004, the plaintiff was also diagnosed with bi-polar disorder, depression and anxiety. She was also further diagnosed with degenerative disc disease, including a herniated disc. In 2005, the plaintiff suffered from severe gastroesophageal reflux disease (GERD). She also underwent a fundiplication to remove a hiatal hernia in 2006.

CIGNA Denies Disability Benefits

On February 1st 2010, the plaintiff was informed by CIGNA that it was reviewing her claim for continuing disability benefits eligibility on the ground that the plaintiff’s claim file did not currently contain information to support continuing long term disability benefits payments. CIGNA specifically cited a Physical Abilities Assessment (PAA) from one of Plaintiff’s physicians, dated November 2nd 2009 which they interpreted as a finding of “sedentary work capacity” and requested any other information that would refute the information provided by the PAA.

To support her claim for continuing long term disability benefits, the plaintiff underwent a Clinical Neuropsychological Evaluation and Functional Capacity Evaluation which concluded that it was doubtful that the plaintiff was able to work with any gainful employment of any type.

CIGNA Denial Letter Sent To Claimant After 12 Years Of Payment

Nevertheless, the plaintiff was informed by CIGNA on July 13th 2010 that she was no longer eligible for long term disability benefits. CIGNA interpreted the phrase “sedentary physical demand level for activity” as having some capacity for working ability the conclusions of the Clinical Neuropsychological Evaluation and Functional Capacity Evaluation. CIGNA also claimed that the plaintiff’s main disability was her psychological health which CIGNA considered as “Mental illness”. This meant that the coverage for long term disability benefits was limited to 24 months only and disregarded ClGNA’s original approval for long term disability benefits in 1999, which is five (5) years prior to the diagnosis of any psychological issues.

CIGNA also claimed that the plaintiff was not undergoing regular treatment for her psychological issues. In her appeal to CIGNA’s decision to deny her claim for long term disability benefits, the plaintiff submitted supporting documents and a letter from her attending physician which specially challenged CIGNA interpretation of the PAA and stated that:

It is difficult to comprehend how you reached the conclusion that Ms. Goble is no longer disabled.

Despite arguments to support her appeal, CIGNA denied that plaintiff’s appeal on November 20th 2010.

Relief Sought In The Lawsuit

In the lawsuit, the plaintiff argued that CIGNA had taken sentences from several reports out of context in order to support its ground for denying the plaintiff’s claim for continuing long term disability benefits. The plaintiff alleged that CIGNA had acted arbitrarily, capriciously and wrongfully by denying the Plaintiff’s claim. As such, the plaintiff is seeking from the Court the following relief:

  • A declaration regarding CIGNA’s noncompliance with minimum requirements of ERISA and other federal and state law in connection with the denial of benefits.
  • Reimburse the Plaintiff for payments she would have been entitled to receive but did not because of CIGNA’s denial.
  • An award of prejudgment interest.
  • An award of reasonable attorneys’ fees
  • An award for costs incurred.
  • An award for any such other relief the Court deems necessary and proper.
  • The plaintiff also demanded a trial by jury.

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