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Benefits Reinstated: Dell & Schaefer Successfully Appeals Cigna’s Decision to Deny Benefits for MetroPCS Wireless Employee with HIV

Forced to leave his position in 2011 due to multiple complications involving HIV/AIDS, Back Issues, Hepatitis C, Depression, etc., a man formerly employed as an Account Service Representative with MetroPCS Wireless applied for and was initially approved for Long Term Disability (LTD) Benefits with CIGNA/Life Insurance Company of North America. These benefits were paid for 24 months as Cigna agreed that he was unable to perform the material duties of his Regular Occupation.

Change In Definition of Disability

Unfortunately for the claimant (and for most people covered under Group Disability Insurance Policies), the definition of disability in the LTD Policy (what it takes to qualify for disability benefits) changes after 24 months of benefits. Previously, in order to qualify for LTD benefits, the claimant just had to prove that he was unable to perform the material duties of his regular occupation as an Account Service Representative. After 24 months, it became harder to qualify for benefits as now the definition of disability changed to be “unable to perform the material duties of Any Occupation for which he or she is, or may reasonably become, qualified based on education, training or experience.”

This change in definition of disability is the most common time for people receiving LTD benefits to be denied by their insurer. In the case of the MetroPCS Wireless Employee, CIGNA did just that. By way of a letter dated September 19, 2013, the claimant was informed by CIGNA that as of December 17, 2013 his claim was denied as it did not believe that his conditions and their accompanying restrictions and limitations satisfied the new definition of disability that became active on December 17, 2013. In support of this conclusion, CIGNA pointed to an Independent Medical Evaluation it had conducted, as well as a Transferable Skill Analysis performed by one of its employees.

Claimant Contacts Dell & Schaefer

The day he was informed that his claim was denied, the claimant contacted Attorneys Dell & Schaefer immediately and spoke with Attorney Alexander Palamara for representation. The fact that the claimant contacted Dell & Schaefer so quickly gave his attorneys the full amount of time to put together an administrative appeal that had no chance of being denied by CIGNA. Armed with updated medical records, a functional capacity evaluation and Social Security Disability Approval, Attorney Alexander Palamara had significant ammunition to challenge CIGNA’s decision. On February 24, 2014, Administrative Appeals were filed challenging CIGNA’s denials on both the Long Term Disability Claim and the Waiver of Premium Claim for his Life Insurance.

Dell & Schaefer Successful

We are happy to report that on April 30, 2014 CIGNA informed the claimant and his attorney that both appeals were successful. CIGNA had agreed to reinstate both his LTD benefits and his WOP claim. Our client is scheduled to remain on claim until he is able to perform the duties of Any Occupation or until he is age 65. Dell & Schaefer will ensure that CIGNA lives up to the promises it contracted to make in the LTD Policy.

If you have been denied by CIGNA or any other disability insurance company (Unum, MetLife, Aetna, Hartford), please contact us to see if Attorneys Dell & Schaefer can be of assistance. We always are available for a free consultation and review of your claim.



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