Claimant in this case was a Senior Systems Engineer with the EMC Corporation. He had a long history of suffering with chronic migraine headaches. As time went by, the headaches worsened in frequency and severity and were accompanied by photophobia, phonophobia, nausea, and vomiting. In the previous two years before he filed his claim, he had also faced the stress of being diagnosed with kidney cancer and undergoing a kidney transplant.
A number of different pain relieving interventions had been utilized to try and decrease his symptoms, but none helped. The increase in frequency of the headaches, accompanied by the disabling symptoms, got to so bad that the claimant found it impossible to perform all of the material duties of his occupation. On May 6, 2016, claimant left work and filed a claim for short term disability benefits (STD).
Cigna’s Denial of Claim for STD Benefits
Cigna denied his claim for STD benefits, stating that the medical evidence did not support the claim. Cigna stated that the evidence failed to show that he suffered from “a functional impairment of such severity that would prevent [him] from performing [his] occupation as a Senior Systems Engineer.” Dell & Schaefer disability attorney, Cesar Gavidia, knew Cigna could not have come to this conclusion if it had reviewed the entire medical and occupational file. So, he filed an administrative appeal.
Appeal From Denial of STD Benefits Claim
It became apparent to Attorney Gavidia that, in its initial review, Cigna had only reviewed one office note dated May 2, 2016, from claimant’s treating physician. It should have reviewed the doctor’s entire file going back to March 2015.
Specially, Cigna stated in its denial letter that “there was no recent neuropsychological testing on file.” In fact, there was a neurological test report dated October 14, 2015. This test result confirmed that claimant suffered from a mild cognitive impairment that interfered with his ability to perform his job.
Also in the file was a note from a peer review physician verifying that claimant’s job performance had declined such that his work had requested he be evaluated and treated. Further, Cigna only contacted claimant’s new physician who had only seen claimant one time. There was no contact with the physician who had been treating claimant for more than a year before the May 6, 2016, date of his claim for STD.
Cigna ignored several other pieces of relevant information. There was no consideration of a report form a neurologist that verified claimant experienced more than 15 headaches a month. Each one lasted at least four hours. There was no consideration of the claimant’s job description and the required job duties of his occupation as a Senior Systems Engineer.
Attorney Gavidia included all the medical and occupational records in the appeal and commented on each individual piece of evidence showing how it supported the claim for STD. He also included individual attending physician statements supporting the diagnosis of Migraine with aura.
All examining physicians agreed with the diagnosis. Claimant’s condition was essentially summed up by one Attending Physician’s Statement that claimant could not perform the duties of his occupation since his headaches interfered with his ability to focus and concentrate. In addition, the doctor stated that claimant would be required to take three to four days off of work every week due to his chronic headaches.
Finally, after months of uncertainty, Cigna overturned its denial and not only paid the short-term disability benefits owed to the claimant, but also approved his claim for long-term disability benefits. Attorney Gavidia will continue monitoring this case and will provide Cigna with information it needs going forward in an attempt to satisfy the Proof of Loss requirements of the policy.
If you have been denied disability benefits by Cigna or any other disability insurance company, feel free to contact Cesar Gavidia at Dell & Schaefer for a free consultation.