In the past 2 years, Dell and Schaefer and Attorney Alexander Palamara have had great success in convincing Life Insurance Company of North America, which is commonly known as CIGNA, that its decisions to deny continued Long Term Disability Benefits to employees of the Palm Beach Sheriff’s Office were incorrect. For our previous story, please visit: https://www.diattorney.com/palm-beach-county-sheriffs-deputys-long-term-disability-claim-reinstated-following-appeal-by-disability-attorney-alexander-palamara/
Like the previous case, our client worked as a Corrections Deputy Sheriff. He was employed in that position since 2007 and due to his employment he was covered under the long term disability (LTD) insurance policy for all sworn Law Enforcement Division Deputy Sheriffs, Sergeants, Lieutenants and other qualified employees.
Unfortunately for our client, due to various conditions that included Low Back Pain, Upper Back Pain, Neck Pain with Radiation to the Bilateral Shoulders, Left Upper Extremity Pain with Radiation to the Left Hand, Bilateral Knee Pain and Swelling, Bilateral Knee Osteoarthritis, Rheumatoid Arthritis, Coronary Artery Disease, he was forced to stop working in July of 2012. Shortly after leaving work, our client filed a claim for benefits with Cigna and benefits were initially approved for the period of January 7, 2013 through January 6, 2016. By later dated December 17, 2015, further benefits were denied as Cigna determined that he did not satisfy the new definition of disability that kicked in after 36 months of benefits.
Like most group disability insurance policies, what it means to be disabled will change after a set period of time. In the Palm Beach County Law Enforcement LTD Policy, for the first 36 months one must prove that he/she is “unable to perform the material and substantial duties of his or her regular occupation…” After benefits are paid for 36 months, to then continue to qualify for benefits, he or she must be “unable to perform the material and substantial duties of any occupation for which he or she may reasonably become qualified based on education, training or experience.” This change in definition is the time in which most approved claims are denied.
Unfortunately for our client, his claim was denied by Cigna at the change in definition of disability. In support of its decision to deny benefits, Cigna relied up on the reviews of a Nurse Case Manager and a Medical Director, both of whom were employees of Cigna. These two reviews led Cigna to believe that our client was now capable of performing a sedentary occupation. Cigna then stated that a “Transferable Skills Analysis” found two occupations that he would be able to perform and denied further benefits as of January 7, 2016.
Alexander Palamara of Dell & Schaefer Files Appeal
After speaking with the client, it was readily apparent to Attorney Palamara that CIGNA’s to decision to deny continued benefits was flat out wrong. It was clear that there was no way that our new client could physically handle the requirements of any occupation for which he may reasonably become qualified based on his education, training and experience.
After gathering Cigna’s claim file and updated medical records from our client’s treating physicians, an administrative appeal was drafted to challenge Cigna’s denial. Our appeal summarized the long history of support of our client’s treating physicians and the objective medical documentation. To further support out client’s claim, our client submitted himself to a medical functional capacity assessment where the Board Certified Physiatrist, after conducting a battery of tests, concluded that the “patient will be unable to maintain gainful employment… secondary to acute, intermitted exacerbations of chronic pain.”
A few months after the appeal was filed, our client, the Palm Beach County Corrections Deputy Sheriff, was reapproved for benefits and continues to receive benefits to this day. Although our client was without benefits for 10 months, he is happy to be back on claim. He also knows that he can trust Dell & Schaefer to keep him on claim until he is able to return to work or until his policy 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.