Our client was previously employed as a Registered Nurse at Hollywood Presbyterian Medical Center in California. She worked faithfully there since 2007. Being a nurse was more than a job, it was her life. Unfortunately for our client, she was forced to stop working in July 2016 when the pain from her lower back issues made it impossible for her to continue to work as a Nurse. She also suffered from depression, anxiety, headaches, and panic attacks, amongst other diagnoses. Luckily for her, her employer provided a long term disability insurance policy should she ever be unable to perform the material duties of her regular occupation.
Shortly after stopping working on July 1, 2016, she filed a claim for LTD benefits with the Life Insurance Company of North America, also commonly known as Cigna. Unfortunately, by way of a letter dated December 28, 2016, Cigna informed her that her claim would be denied as Cigna believed “that the medical information (did) not support restrictions” and “that the opinion of your medical provider is not well supported by medically acceptable clinical or laboratory diagnostic technique and is inconsistent with the other substantial evidence in the claim file.” Unsure as to how in the world Cigna could have come to this conclusion, our client knew that an appeal had to be filed.
An initial appeal was filed to challenge Cigna’s December 28, 2016 denial, but unfortunately that appeal was not successful. By way of a letter dated December 13, 2017, Cigna upheld its previous decision as it believed that its prior decision was correct. In support of this conclusion, Cigna relied upon the “independent” reviews of a doctor of occupational medicine and a doctor of psychiatry. These doctors both found no support that the former nurse would have functional limitations from the time she stopped working, despite evidence from MRI’s that was objective. Undeterred, our client knew that there was enough proof that she was disabled under the terms of the policy and with the help of Attorney Alexander Palamara a second administrative appeal was filed to challenge Cigna’s denials.
The June 8, 2018 Administrative Appeal:
In the June 8, 2018 administrative appeal, Attorney Palamara first pointed to the support of the treating physicians to show that Cigna’s denials were unfair as well as arbitrary and capricious. For instance, her psychiatrist wrote in one letter that his patient “cannot concentrate sufficiently to administer medications, and cannot yet relate to patients.” Later, the psychiatrist noted in another letter that his patient was a “Class 5” impairment, meaning she had “significant loss of psychological, personal and social adjustment.” Likewise, our client’s primary care physician wrote that she was “unable to perform duties as registered nurse.” In a later note, the primary care physician wrote that her patient was homebound, unable to drive, unable to lift, and could perform no work activity as a nurse.
After pointing to the physician support, the appeal then took issue with the reviews Cigna relied upon. With regards to the psychiatric review, Attorney Palamara noted that the reviewing psychiatrist’s report merely focused on statements from the medical documentation that supported what seemed to be a pre-determined goal of supporting Cigna’s desire to deny the claim. The reviewing doctor conveniently overlooked any documentation in the records that clearly supported the fact that our client had mental conditions that prevented her from working as a nurse. Furthermore, Attorney Palamara criticized the fact that the peer review only reached out to a treating doctor who last treated the client 18 months earlier, but never attempted to reach out to the current treating provider.
Similarly, Mr. Palamara took issue with the review by the occupational medicine doctor. That doctor obviously overlooked the objective documentation and also ignored the findings/opinions of the treating physicians. Like the psychiatric review doctor, the occupational medicine doctor reached out only to our client’s mental health providers and not the physicians who treated her physical ailments, which was illogical.
Lastly, Attorney Palamara pointed to objective and subjective evidence in the claim file to drive home the point that there was no question that our client cannot perform the duties of her own occupation as a nurse and to conclude otherwise is flat out wrong. For instance, the results of the MRI’s of the spine were quite clear. The arguments left Cigna with no choice but to finally approve this claim.
Claim is Finally Approved
On August 29, 2018, over 2 years after initially leaving work, Cigna agreed that our former nurse was disabled and approved long term disability benefits. Back benefits from the time benefits should have initially begun were paid. Our client is ecstatic to be finally be approved for benefits and is happy that she found attorneys to get her on claim.
Although her claim is currently approved, she realizes the fight is not over as a claimant must continually prove that he or she satisfies the definition of disability. However, our client knows that Dell & Schaefer will do whatever it takes to keep her on claim until she is able to return to work or until her policies expires.
If you have been denied disability benefits by Cigna or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.