Our client, Ms. N, had been employed with Sears Holdings as a customer service representative, before pain and discomfort from fibromyalgia and degenerative disk disease (DDD), caused her to file a disability claim under the Sears Long-term Disability Plan. Sears had contracted CIGNA to insure and administer the disability plan.
The pain and discomfort which resulted from the combined effects of fibromyalgia and DDD were overwhelming, not only physically but also emotionally for Ms. N.
Unfortunately, when CIGNA denied her claim for benefits it only added insult to injury. Following her denial of benefits, Ms. N’s initial impulse was to contact CIGNA and inform them that she was appealing her claim. Like most people, Ms. N was not aware that what she submitted in her administrative appeals would be critical if she was to ever pursue a lawsuit against CIGNA for recovery of her long-term disability benefits, since ERISA generally only allows for the court to consider the administrative record (ie., documents and evidence submitted to the insurer during the claim and administrative appeals process) when decided a long-term disability claim.
After exhausting all of her appeals, Ms. N contacted Dell & Schaefer to discuss her remaining options in order to recover her disability benefits. Although we believed, after reviewing her case, that the administrative record could have been better supported through the inclusion of attending physician questionnaires, medical narratives and perhaps a functional capacity examination performed by a true independent expert, we felt that there was enough evidence showing that CIGNA had wrongfully denied her claim.
Cesar Gavidia and his team at Dell & Schaefer sued CIGNA, alleging that the disability insurance carrier had violated ERISA and wrongfully denied Ms. N access to her long-term disability benefits. Of course, CIGNA answered the lawsuit by denying the allegations. Notwithstanding, the case was later settled under terms which remain confidential.
As disability insurance attorneys, we believe that the administrative appeal is possibly the most important part of the long-term disability claim process. The inclusion or exclusion of a specific documents or piece of evidence could mean the difference between recovering disability benefits, or the case being dismissed on summary judgment by a federal judge. For this reason, we always advise that claimants retain legal counsel with experience handling ERISA disability cases to tackle the administrative appeal, and only when left with no other choice, and as a last resort, should the claimant submit their own appeal.