Cigna Approves Any Occupation Disability Benefits After Two Appeals
Author: Attorney Stephen Jessup
Prior to filing for long term disability benefits with Cigna, our client worked as a coordinator for a large hospital system. After having double knee replacements he found the physical demands of his job to be too strenuous in light of his ongoing pain and movement limitations. Left with little choice he filed a claim for disability benefits with Cigna. Based on the information provided Cigna approved his claim for benefits under the Own Occupation period definition of disability and issued benefits for 24 months, at which time Cigna advised him that he no longer qualified for benefits under the Any Occupation definition of disability as it had determined he was capable of Sedentary Work duties. Like many other insureds on claim with Cigna, this determination was made despite the fact Cigna had assisted him in obtaining his Social Security Disability benefits.
The First Appeal
Like many people, our client did not initially understand the importance of an appeal under a policy governed by ERISA, and took his claim manager’s word that all he had to do was write a letter stating why he disagreed with the denial. Our client did just that and shortly after receiving the denial letter he submitted a brief appeal. Shortly thereafter he received notice that Cigna was upholding its denial of his claim for benefits as Cigna determined that our client failed to submit evidence of his inability to work at a sedentary demand level.
The Second Appeal
Following the second denial letter, our client contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup. Attorney Jessup informed our client as to the nature of litigation under ERISA disability policies and how failure to provide all information necessary to prove disability on Appeal could prevent an insured from bringing additional evidence into the record at trial. Thankfully for our client his disability policy with Cigna allowed for a voluntary second appeal.
Like many insureds our client never obtained a copy of his claim file nor did he know that he was entitled to same; as such Attorney Jessup secured a complete copy of our client’s claim file and began immediately looking for ways to counter the arguments made by Cigna’s medical reviewers. Attorney Jessup also secured medical records from our client’s treatment providers and coordinated for additional testing that would help document our client’s physical restrictions and limitations and that would effectively nullify Cigna’s position that he was capable of performing full time Sedentary work. What made the case more challenging was the fact that by the time Attorney Jessup became involved our client’s claim had been terminated for nearly nine months. As such, Attorney Jessup had to not only establish physical disability at the present time but also effectively argue that the impairments being documented currently were also in effect almost a year earlier.
After all the information was gathered and arguments were finalized, Attorney Jessup submitted our client’s voluntary and final appeal. Faced with overwhelming evidence to support continued restrictions and limitations that would prevent our client from working, Cigna notified our Office that it was reinstating our client’s benefits. After almost a year without monthly benefits Cigna forwarded a check representing all back benefits owed and placed our client back on claim.
If your long term disability benefits have been denied do not trust your insurance company that writing a simple letter will in and of itself suffice to having your benefits reinstated. Under ERISA governed disability insurance policies your Appeal will form the basis of all information you will be able to argue in the event you have to file a lawsuit, as such it is always wise to consult with an attorney before filing an appeal.
If your claim has been denied and you need to file an Appeal do not hesitate to contact our office to discuss how we may be able to assist you.
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