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Attorney Cesar Gavidia successfully appeals Cigna claim denial after Cigna and its medical consultant deny claim alleging that restrictions were not medically supported by the medical records

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Prior to his disability, Mr. F was employed as a Contractor Field Service Representative with a large aerospace company. As one of his employee benefits, Mr. F was provided with group long-term disability insurance through CIGNA. In 2011, Mr. F was involved in a motor vehicle accident and suffered fractures and injuries to his head, neck, back and femur. The doctors treating Mr. F decided to place him in a medically induced coma to properly treat his injuries. When he awoke he began experiencing terrible headaches which only worsened over time. The accident and the resulting injuries marked the end of his carrier in the aerospace field and forced Mr. F to file a long-term disability claim with CIGNA.

Initially, CIGNA seemed eager to help and even assisted him in gathering all of the necessary medical and occupational information it needed to conduct its review. After approximately 5 weeks, CIGNA approved Mr. F’s claim and began paying benefits. Over the course of the next two years, CIGNA requested little more than updated claim forms and physician forms from Mr. F’s treating doctors.

CIGNA Terminates Long-term Disability Claim Following Medical Consultant’s Review

Two years after initially approving Mr.F’s claim and finding that he was unable to perform his own occupation as a field service representative, CIGNA notified Mr. F that, due to a change in the definition of disability, it must determine whether he was capable of performing the substantial and material duties of any gainful occupation. A short time later CIGNA informed Mr. F that his claim was reviewed by an in-house medical consultant and a vocational rehabilitation specialist, and that based on their findings his restrictions were not medically supported. In addition, CIGNA informed Mr. F that its vocational specialist found that he was capable of performing at least three different “gainful” occupations. Based on the reports from their medical consultant and vocational specialist, CIGNA terminated Mr. F’s claim and discontinued benefits.

Mr. F contacted Attorneys Dell & Schaefer and retained Attorney Cesar Gavidia to represent him with his mandatory appeal of benefits. Attorney Gavidia discovered that CIGNA was aware that Mr. F was receiving social security disability benefits and had reduced his monthly disability benefits by the amount he was receiving from SSDI, yet completely ignored the SSA’s medical findings concerning Mr. F’s restrictions and limitatinos. In addition, the medical consultant retained by CIGNA never contacted any of Mr. F’s treating physicians to discuss the restrictions and limitations they imposed, and never directly examined Mr. F as part of his review.

After completing his analysis of CIGNA’s claim review and compiling all of the necessary evidence, Attorney Gavidia and his team submitted Mr. F’s appeal to CIGNA. Approximately two months after receiving the appeal, CIGNA communicated that it was overturning its decision to deny benefits, paying all benefits due and placing Mr. F on claim.

Currently, Mr. F remains on claim with CIGNA, while Attorney Gavidia monitors CIGNA and the claim to mitigate the likelihood of any future interruption in benefits.

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