Fresenius Medical Care North America Employee Wins Disability Appeal With CIGNA
Due to conditions that included Polyneuropathy, Encephalopathy, Osteomyelitis, Radiculitis, and Degenerative Disc Disease with Myelopathy, a Registered Nurse of Fresenius Medical Care North America was forced to stop working in June of 2012. Luckily for her, her employer provided coverage under a Long Term Disability (LTD) Insurance policy with CIGNA should she be unable to perform the material duties of her regular occupation for 24 months and then unable to perform the material duties of any occupation for which she is qualified based on education, training or experience for the time thereafter. Although applying for benefits was nerve wrecking, her claim for LTD benefits was approved and benefits were paid by CIGNA and commenced on December 11, 2012. Shortly thereafter, the Social Security Administration (SSA) also found her to be disabled and began paying Social Security Disability Benefits. Although her Social Security Disability Benefits allowed CIGNA to pay her at a decreased amount per month as they get to offset the money she receives from the SSA, her approval for such benefits gave her a false confidence that CIGNA would continue to pay benefits until her policy expired at age 65 or until she was able to return to work.
Denial of Continued Disability Benefits by CIGNA
As mentioned above, under the terms of this LTD Policy (and most Group LTD Policies), what it means to be disabled changes after 24 months of benefits are paid. For the first 24 months, in order to qualify for benefits, a claimant must prove that he or she is “unable to perform the material duties of his or her regular occupation” and that he or she is “unable to earn 80% or more of his or her indexed earnings from working in his or her regular occupation.” After 24 months of benefits, however, what it means to be disabled changes and becomes tougher to satisfy. At that time, in order to continue to receive benefits, a claimant must then prove that he or she is “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.” Furthermore, the claimant at that time must now be “unable to earn 60% or more of his or her indexed earnings.” Thus, after 24 months of benefits, it is an “any occupation” standard with a lower threshold of earnings capacity. This is often the time when insurance companies deny continued claim for benefits.
Unfortunately for this Registered Nurse of Fresenius Medical Care North America, CIGNA denied continued benefits beyond December 10, 2014, the date in which the change in definition of disability was occurring.
Claimant Filed an ERISA Appeal on Her Own
After receiving the LTD denial letter, the Registered Nurse filed an Appeal on her own to challenge CIGNA’s decision. This 3 page appeal was followed up with 2 more pages a week later that argued that she would not be hired for the positions that CIGNA believed she could do. Unfortunately for the claimant, CIGNA upheld its decision to deny her continued claim for benefits. Within hours of receiving the 2nd denial letter, the Registered Nurse contacted Dell & Schaefer for assistance in righting this wrong.
Alexander Palamara of Dell Disability Lawyers Gets Involved
After speaking with the claimant, Disability Attorney Alex Palamara knew that CIGNA’s decision was wrong. It was apparent that this Registered Nurse had disabling conditions that satisfied all the terms of the policy. The new denial letter allowed for an optional 2nd ERISA Appeal or allowed the claimant to file an ERISA lawsuit. Immediately upon agreeing to take on the case, Attorney Palamara ordered the Claim File from CIGNA and updated medical documentation from her treating providers. Upon receipt of all the documents, it was clearer than ever that the objective evidence proved that she is “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” and “unable to earn 60% or more of his or her indexed earnings.” Knowing that the claim file was not as strong as it needed to be and knowing that there was a high chance of success with filing an appeal, the decision was made to file a 2nd appeal instead of commencing litigation.
This 2nd appeal was timely filed. This appeal summarized all the medical records and made arguments as to why the Registered Nurse’s claim should never have been denied in the first place. On November 23, 2015, CIGNA informed us that “a determination has been made that the prior decision should be overturned.” On December 1, 2015, all the benefits that should have been paid from December 11, 2014 to that time period were paid. Although our client had not been paid for a year, she was relieved to be back on claim. She is also confident knowing that Dell Disability Lawyers continues to represent her as she knows it will help prevent CIGNA from denying her claim again in the future. She continues to receive her monthly benefit.
If you have been denied disability benefits by CIGNA or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell Disability Lawyers for a free consultation.
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Q: I filed an appeal and lost. Is it worth pursuing?
A: Kim, in my opinion, yes. If you are still within your timeframe to file a lawsuit you have little to lose in t... Read More >
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A: Frank, we would need to see a copy of the denial letter and the policy. Please feel free to contact our office... Read More >
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A: Tret, Cigna will be required by law to provide you with a written denial letter setting forth its reason for t... Read More >
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A: SB, ERISA provides 45 days to render a decision on appeal with the possibility of a 45 day extension- basicall... Read More >
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Who are Dell Disability Lawyers?
We are disability insurance attorneys that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.
Our attorneys have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement in more than 98% of our cases. Our disability insurance lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.
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Our disability insurance attorneys help individuals that have either purchased a long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer. We have helped individuals in almost every type of occupation with monthly disability benefit payments ranging from $1,500 to $50,000.
Our clients include all types of employees ranging from retail associates, sales representatives, government employees, police officers, teachers, janitors, nurses, pilots, truck drivers, financial advisors, doctors, dentists, veterinarians, lawyers, consultants, IT professionals, engineers, professional athletes, business owners, and high level executives.
A strong understanding and presentation of the duties of your occupation is essential for securing disability insurance benefits.
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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability insurance lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.
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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.
The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.
In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.
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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via phone, email, fax, or video conferencing sessions. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.
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When you call us during normal business hours you will immediately speak with a disability insurance attorney. We can be reached at 800-698-9159 or by email. Lawyers and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.