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Cigna Approves Disability Benefits to Doctor with Ehlers-Danlos

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

Our client, an oncologist with a focus in hematology, was born with and had suffered most his life from Ehlers Danlos Syndrome (EDS), a connective tissue disorder with a wide range of affects and symptoms, which presented itself in his case with a history of frequent bone breaks, multiple surgeries throughout his life, hypermobility and chronic debilitating pain. Despite an early history of chronic pain and issues related to EDS he had completed medical school and residency and specialty training in oncology/hematology. Throughout his medical career he dedicated his time and effort to treating and battling blood based cancers such as leukemia, lymphoma and myeloma. As a member and partner of a small but fast growing medical practice our client was for all intents and purposes set. However, not everything was as it would seem as the long hours and stress of the job, physically, mentally and emotionally, was leading to increased symptoms from his EDS. In an effort to find relief our client went so far as to travel to Johns Hopkins to treat with a specialist as to his diagnosis of EDS and to obtain a second opinion as to further treatment options. Despite his best efforts our client continued to suffer severe pain that affected his ability to concentrate, which in turn created huge concern as to his ability to provide the best medical care to his patients. Knowing that his work required life and death decisions he found himself at a crossroads- to continue to find a way to work or walk away from his life’s work and his successful medical practice. True to his Hippocratic Oath, he decided that his medical condition was affecting his ability to provide the level of care for his patients that he would want for a member of his own family. At that time our client filed his claim for long term disability benefits under his practice’s group disability policy with Cigna.

The First Denial

Despite a lengthy medical history and extensive medical records supporting restrictions and limitations, Cigna advised our client that it was denying his claim for long term disability benefits following a review by one of Cigna’s medical directors, which had determined that there was a lack of medical evidence to support restrictions and limitations that would prevent him from performing the material duties of his occupation as an Oncologist/Hematologist. Even more insulting was the fact that Cigna’s denial letter advised our client that his occupation was a “Light” duty demand occupation and that based on its review Cigna determined he could perform at a light duty demand level and as such could, in turn, work as a doctor. Cigna essentially equated our client’s ability to medically treat blood born cancers to nothing more than the ability to perform light duty work. Making matters worse, Cigna’s medical director did not take into consideration any of our client’s actual occupational duties when he opined that there was nothing preventing him from working in his pre-disability occupational capacity. To say that our client was surprised by the claim denial is an understatement as our client, like most people, expected his insurance company to do the “right thing.” Our client then filed his Appeal of Cigna’s denial of his claim for benefits on his own.

The Second Denial

Typical of Cigna, on appeal Cigna sent our client’s file to an outside medical reviewing doctor (as opposed to relying on internal medical employees as they did during the application) to determine if there was sufficient evidence to support restrictions and limitations that would prevent him from performing his occupational duties. During the course of the appeal review, Cigna’s independent doctor spoke to, and ultimately relied exclusively, on the opinion of the specialist from Johns Hopkins, who our client had only treated with once for a second opinion. Having no history or pattern of treatment with client to draw upon, and limited knowledge of his medical difficulties in light of his work requirements, the specialist reportedly indicated to Cigna’s doctor that our client would be able to work despite his EDS. Armed with this opinion, Cigna’s doctor did not bother to communicate with any of our client’s treating physicians as to any applicable medically necessary restrictions and limitations. Cigna, in turn, denied our client’s appeal.

The Final Appeal

Having fought with Cigna for almost a year our client contacted Attorneys Dell & Schaefer to seek assistance with filing his voluntary second (and final) appeal of Cigna’s denial of benefits and spoke with Attorney Stephen Jessup. Although our client had the benefit of filing a voluntary appeal with Cigna, unlike the mandatory first appeal, Cigna had no legal obligation to send our client’s file to new physicians for review and could (and would) return all updated information to the doctors who initially reviewed the first appeal. Essentially, Attorney Jessup had to convince Cigna’s doctors that their already expressed opinions were wrong, and even more difficult – get them to admit it.

Due to the fact that much of Cigna’s basis for denying our client’s claim to that point revolved around the requisite physical ability to perform at what Cigna deemed to be a “Light” duty level, Attorney Jessup’s first course of action was to arrange for an independent medical examination, to include functional capacity testing, with a doctor board certified in rehabilitative and occupational medicine. The IME and subsequent FCE resulted in objective functional testing and expert witness medical opinion that supported our client’s inability to not work at the physical demand level that all of Cigna’s doctors had previously determined. Armed with the supportive functional testing, Attorney Jessup set about systematically undermining Cigna’s medical and occupational file reviews to prove without a doubt that our client was medically unable to return to the practice of medicine.

Nearly three months after the appeal was submitted, Cigna notified our office that it was overturning the denial of our client’s benefits, paying almost eighteen months in back benefits, and placing him on monthly claim handling.

Our client contacted our office when he was at his wit’s end dealing with Cigna. Cigna had made the whole process so difficult that our client contemplated walking away from the disability policy completely. Attorney Jessup continues to represent our client to ensure that Cigna honors its contractual obligations with our client.

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If you suffer from Ehlers-Danlos Syndrome and your disability carrier is fighting your claim, or you have questions and/or concerns about a disability, or potential disability claim please feel free to contact our office to speak with one of our disability insurance attorneys.