Cigna Again Reinstates Claim of Archdiocese of Baltimore Registered Nurse Thanks to Appeal by Dell & Schaefer
Author: Attorney Alex Palamara
A Registered Nurse was initially forced to stop working in 2013 due to various conditions, including: enthesopathy in the hip region, lumbago, myalgia/myositis, lumbar spondylosis, lumbar degenerative disc disease, lumbar facet syndrome, and chronic pain syndrome. When the pain from her multiple medical conditions left her unable to work, the RN immediately applied to Cigna for STD benefits, but was initially denied. At that time, Cigna claimed there was insufficient evidence to support her disability, noting a lack of objective medical evidence and diagnostic tests to support her claim.
Unfortunately, the former RN was unable to work and knew Cigna’s conclusion was wrong. Dismayed her claim was denied and confused by Cigna’s rationale for denying her claim, she decided to find assistance with her claim and found Attorney Alexander Palamara of the Dell & Schaefer law firm. The former RN made the right decision, because Cigna’s denial of her STD claim would only be the first of many denials of the RN’s claims for disability benefits despite worsening medical conditions and additional diagnoses of systemic lupus erythematosus and peripheral vascular disease.
Dell & Schaefer Gets Involved
After reviewing Cigna’s claim file and speaking with the former RN, it was clear that not only had Cigna improperly denied her STD benefits, but that her claim for LTD would likely be improperly denied despite sufficient medical evidence to support the former RN’s claims for both STD and LTD benefits. As anticipated, the former RN’s LTD benefits were denied in May of 2014.
The claim files regarding the STD and LTD benefits from Cigna were ordered, as well as the updated records from our now client’s treating physicians. After compiling and reviewing all the necessary information, it was clear that benefits should be reapproved since our client had overwhelming support from her primary care physician and supportive diagnostic studies. To provide additional support to Cigna of her claims, the former RN also underwent a Functional Capacity Evaluation. Two appeals were then filed on behalf of the former RN, one for STD benefits and one for LTD benefits. The appeals focused on the objective medical evidence which supported the existence of our client’s medical conditions, but also critiqued Cigna’s failure to obtain any type of objective medical opinion regarding our client’s conditions and highlighted the improper standards used by Cigna to justify its denials.
As a result of the STD appeal, Cigna overturned its denial and STD benefits were paid in full. As a result of the LTD appeal, Cigna also overturned its denial and commenced payment of LTD benefits. However, the work was not over for Attorney Palamara since it was clear our client would not be returning to work and it was likely Cigna would make another attempt to deny the claim for LTD benefits.
Once again, as anticipated, in July of 2016 Cigna notified the former RN and Attorney Palamara that the claim was approaching the “change in definition” date under the policy and her claim was being reevaluated to determine whether the former RN was capable of performing “any occupation” instead of her “own occupation.”
Despite providing updated medical information and all necessary paperwork to Cigna, Cigna once again denied LTD benefits to the former RN. However, in support of the denial after the change in definition of disability, Cigna had the former RN undergo an independent medical evaluation, making the denial more difficult to overcome.
Despite Cigna being able to rely on the results of the IME in support of its denial, Attorney Palamara diligently reviewed all the updated medical information and claim file to find the medical records revealed consistent exam findings which supported the former RN’s credible complaints of severe, refractory pain. The results of Cigna’s IME also showed the RN was credible. Attorney Palamara highlighted the records evidencing subjective complaints and argued they must be considered in evaluating disability. Attorney Palamara also argued a claimant cannot be required to produce “objective” evidence or measures with regard to pain complaints.
This first appeal after Cigna’s denial due to the change in definition of disability was denied. In its second denial letter Cigna relied upon the review by one of its in house Medical Directors and concluded a review of the medical information on file failed to provide a physical impairment or clinical findings indicative of a functional loss to preclude the former RN from performing the duties of any occupation.
Attorney Palamara once again obtained updated medical information from our client’s treating physicians and reviewed Cigna’s claim file. Upon review of all updated information, It was clear Cigna did a poor job in relying upon the opinion of its medical director, who was advised by our client’s treating physician that she is unable to work due to chronic pain and the side effects from prescribed pain medication. The medical director did not provide any explanation for ignoring the information from our client’s treating physician, but merely cited to a lack of consistent or credible medical documentation to support functional limitations due to narcotic pain medication, consistent findings of normal mental status, and a lack of consistent side effects noted from the pain medication. The medical director’s opinion was clearly false or misleading based upon a review of the medical records.
A second appeal was filed and three months later, Cigna overturned its denial. Although our client endured numerous denials by Cigna, she is now happy to be receiving benefits once again. Attorney Palamara continues to represent our client to best ensure that Cigna will not terminate benefits once again.
Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.