In 2011, Kris was involved in a serious motor vehicle accident which resulted in a severe closed head injury, hangman’s fracture (fracture of the C2 spine), and multiple orthopedic fractures including a femur fracture. He required multiple surgeries and was placed in a medically-induced coma for 4 days. Following the accident, Kris continued to suffer from chronic daily headaches, memory and cognitive problems, mood swings, depression, difficulty with walking and balance, and difficulty following instructions.
Prior to his accident and resulting disability, Kris enjoyed and succeeded in his profession as a Technology Manager with Lockheed Martin, one of the world’s largest aerospace and defense companies. Following the accident, CIGNA did not question the extent of Kris’ injuries and approved his claim for long-term disability benefits without almost any hesitation. For the next three years, CIGNA only asked for periodic claimant update statements, attending physician forms certifying ongoing disability and medical records to keep up to date with Kris medical treatment and status.
CIGNA’s Medical Consultant Review, Vocational Assesment, and the Termination of the Long-term Disability Claim
However, in 2014, CIGNA decided to part from its routine and have Kris’ claim reviewed by its Associate Medical Director, Dr. Mendez. Dr. Mendez purportedly reviewed Kris’ medical records and decided that Kris’ restrictions were no longer continuously medically supported retroactively from 2013, despite acknowledging that Kris continued to have restrictions ambulating, sitting and even standing.
After obtaining the report from Dr. Mendez, CIGNA then had Kris’ claim reviewed by an in-house vocational consultant that paired Kris, based on his education, training and experience with several occupations he had never performed and some he had never even heard of.
Armed only with the reports from its medical and vocational consultant, CIGNA terminated Kris’ long-term disability claim after 4 years of finding him totally disabled from any gainful occupation.
Team Led by Attorney Cesar Gavidia Appeal CIGNA’s Wrongful Termination of Benefits and Win.
Soon after receiving his termination of benefits, Kris contacted Attorneys Dell and Schaefer, and hired Attorney Cesar Gavidia and his appeal team who promptly began gathering evidence for the administrative appeal. Several major flaws and evidence of arbitrary and capricious conduct were highlighted in the appeal, including CIGNA rush to judgment in contradiction to the medical evidence, CIGNA’s failure to conduct a physical examination of Kris, as well as CIGNA’s failure to weigh or even consider Kris successful receipt of social security disability benefits, which CIGNA financially benefited from by reducing the monthly benefits payable to Kris.
After seeking an extension to conduct its review, and after approximately 3 months from when the appeal was submitted, CIGNA overturned its erroneous decision to deny benefits and reinstated Kris long-term disability claim. Currently, Kris remains on claim and continues to receive his monthly long-term disability benefits, while Attorney Gavidia and his team monitor his medical treatment and CIGNA’s ongoing claim handling.