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Federal Court provides 5 reasons CIGNA wrongfully denied disability benefits to man suffering from chronic fatigue syndrome

Citing a financial incentive to cheat, the United States Court of Appeals for the Ninth Circuit recently overruled the decision of CIGNA (CI) to deny disability benefits to a man suffering from chronic fatigue syndrome. For anyone disabled by chronic fatigue or fibromyalgia this is a very supportive case and great law. The court provided five reasons that Cigna abused its discretion by denying disability insurance benefits. Let’s take a close at the case history and the court’s reasoning.

Disability Claim Background

Harvard and Massachusetts Institute of Technology graduate Samuel Salomaa was described as an ideal employee of the American Honda Motor Company. His supervisor described him as “without a doubt the best employee to have worked for me.” Salomaa never got sick, never left work early nor arrived late for more than 20 years. However, that all changed after suffering a bout with the flu in 2003. After a few days off, Salomaa attempted to return to work, but something was different. The smallest of tasks left him completely exhausted and he even showed signs of diminished intellectual capacity.

After several months of working on a diagnosis, Salomaa’s physicians diagnosed him as suffering from chronic fatigue syndrome. One physician wrote that “since beginning our Kaiser Permanente Chronic Fatigue/Fibromyalgia Clinic in 1992, Mr. Salomaa is one of the more severe patients that I have seen in the clinic”¦ Mr. Salomaa is totally disabled and would not be able to work even 30 minutes per day on a daily basis.” Additionally, the director of the New Jersey Medical School Chronic Fatigue Syndrome/Fibromyalgia Center also stated that after personally examining him, he found Mr. Salomaa to be suffering from the most severe case of the elusive disease he had ever seen.

With such a diagnosis and medical support, Salomaa applied for his employer provided long-term disability benefits as well as Social Security Disability benefits. He was approved by the Social Security Administrator, but was denied by CIGNA, the claim administrator of the plan provided by his employer. In denying the claim, the claim manager from CIGNA wrote that the lack of objective physical findings formed the basis for the denial. She also noted in error that Mr. Salomaa had “no fevers or weight loss,” when in fact he had lost 14% of his body weight in six months, and she stated that his “depression had improved”, when in fact he had never suffered from depression. The claim administrator also stated that she relied on her “medical department’s” review in reaching her decision, when in fact she meant that one physician had read Salomaa’s medical file and wrote his opinion.

Disability Lawsuit and The Court’s Findings

After exhausting all of his administrative appeals, Mr. Salomaa and his California disability attorneys filed an ERISA disability lawsuit in 2006. The United States District Court For the Central District Of California upheld CIGNA’s determination after it determined that CIGNA did not abuse its discretion in reaching its decision. Mr. Salomaa’s California disability lawyers immediately filed an Appeal with the Ninth Circuit Federal Court of Appeals. The Court of Appeals reversed the lower court and provided five reasons to support their decision. The Court of Appeals found that, “(i)n this case, the plan abused its discretion. Its decision was illogical, implausible, and without support in inference that could reasonably be drawn from facts in the record, because:

  1. every doctor who personally examined Salomaa concluded that he was disabled;
  2. the plan administrator demanded objective tests to establish the existence of a condition for which there are no objective tests;
  3. the administrator failed to consider the Social Security disability award;
  4. the reasons for denial shifted as they were refuted, were largely unsupportive by the medical file, and only the denial stayed constant; and
  5. the plan administrator failed to engage in the required ‘meaningful dialogue’ with Salomaa.”

The Court noted the frustration that disability plan administrators can experience when dealing with claims based on diseases such as chronic fatigue syndrome and fibromyalgia. Such diseases have an absence of objective proof such as x-rays or blood tests which show its existence or non-existence. Such diseases create the risk of false claims. However, the Court pointed out, that claimants are not the only ones with an incentive to cheat. The Appellate Court stated that:

“the plan also has a financial incentive to cheat. Failing to pay out money owed based on a false statement of reasons for denying is cheating, every bit as much as making a false claim. The plan has no exception to coverage for chronic fatigue syndrome, so CIGNA has taken on the risk of false claims for this difficult to diagnose condition. Many medical conditions depend for their diagnosis on patient reports of pain and other symptoms, and some cannot be objectively established until autopsy. In neither case can a disability insurer condition coverage on proof by objective indicators such as blood tests where the condition is recognized yet no such proof is possible.”

In the end, the Appeals Court found that CIGNA abused its discretion and found that its decision to deny Salomaa’s claim was arbitrary and capricious. The Court awarded Mr. Salomaa his long-term disability benefits.

Salomaa v. Honda Long Term Disability Plan (9th Cir. – March 7, 2011).

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FAQ

Do you help Cigna claimants nationwide?

We represent Cigna clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Cigna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Cigna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Cigna.

How do you help Cigna claimants?

Our lawyers help individuals that have either purchased a Cigna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Cigna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Emily H. (Massachusetts)

Rachel and team were professional, knowledgeable and competent in helping me with my disability insurance claim denial. I would not have been able to do this work myself successfully.  I had an illness best known as Chronic Lyme (I have more issues than that but that’s what I understood my diagnosis to be at the time of claim denial). This is a complex illness that is plagued with faulty testing, delayed diagnosis, inconsistent prognosis/ treatment outcomes, and vague (deniable) symptoms.

Advances in the disease’s treatment have stalled for decades due to financial & reputational conflicts of interest that exist across the healthcare/ insurance / government industries. It is a major thing to go against, and a very complex & constantly evolving issue, and Rachel was very familiar with all the chronic Lyme ‘inside baseball.’ Not many people want to get involved with anything Chronic Lyme-related if they have a choice. Finding an attorney that has expertise in this area is a rare find, and I can attest to the fact that Rachel meets this hard-to-find criteria and delivered results well beyond what I could have achieved without her.

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