After appeal filed by Attorney Jay Symonds, CIGNA overturned its previous denial of short term disability benefits for New Jersey Project Manager
Author: Attorney Jay Symonds
Our client, Mr. W, formerly worked as a Senior Project Manager of an Industrial building/construction contractor. In May 2015 a number of medical issues, including chronic pain syndrome, cervical post laminectomy syndrome, cervical pseudarthrosis, as well as degenerative cervical joint disease, cervical facet arthropathy, spinal stenosis, forced Mr. W to stop working and submit his claim for disability benefits, first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. The STD coverage was funded by his employer but claims were administered by CIGNA. Mr. W’s occupation as Project Manager was physically and intellectually demanding and required regular travel and working at heights approaching 1000 feet above ground. Under his employer’s STD policy, he would be considered totally disabled if he was unable to perform the material and substantial duties of his own “regular occupation.”
After paying Mr. W for three (3) months under the STD policy, CIGNA denied further STD benefits on the basis that Mr. W allegedly no longer met the policy definition of disability. Specifically, CIGNA determined that “[t]here was no evidence to demonstrate functional impairment…[therefore] the claim remains closed and no further action will be taken on the claim at this time.” After receiving the denial, Mr. W contacted Attorneys Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in CIGNA’s denial letter and in the physician consultant’s medical reviews, and agreed to prepare and submit Mr. W’s ERISA appeal with the assistance of his appeal team. In addition, Attorney Symonds recommended that Mr. W initiate an LTD claim simultaneous with the STD appeal.
The STD appeal addressed all of CIGNA’s short-comings and reasons for denial, with a special focus on the review conducted by CIGNA’s in-house nurse consultant and CIGNA’s assessment of the material and substantial duties of Mr. W’s regular occupation. In particular, the appeal identified several mischaracterizations and misinterpretations of Mr. W’s medical records by CIGNA’s in-house medical staff. In addition, the appeal established CIGNA’s failure to recognize and address the fact that Mr. W’s regular occupation was quite complex, detail oriented and physically demanding.
Approximately 2 months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, CIGNA overturned its decision to terminate the claim and reinstated and paid Mr. W’s short-term disability benefits through the maximum benefit period. At the same time, Mr. W’s LTD benefit claim was approved and he began receiving payments avoiding an unnecessary delay or gap in monthly income.