Trinity Health Care Registered Nurse wins Cigna long term disability Appeal
After receiving Long Term Disability (LTD) benefits for two years due to severe back conditions, a Nurse who formerly worked at Albany Memorial Hospital (which is part of the Trinity Health System) was denied continued LTD benefits after Cigna made a determination that she no longer satisfied the definition of disability under the policy.
The timing of such a denial is very common in the disability insurance world. As some don’t realize, most group disability insurance policies that are given to employees from their employers often contain fine print that states that the definition of disability (what it means to be disabled under the policy) changes after 24 months of benefits. Typically under most group policies, in order to qualify for benefits for the first two years, one most prove that he/she is “unable to perform the material duties of their own occupation.” Unfortunately, after two years, it then becomes more difficult to qualify for benefits as you now must prove that you are “unable to perform the material duties of any occupation you are qualified for based on your training, education or experience.” Insurance companies use this new definition of disability to deny many people on claim. In fact, it is the most common reason for a denial of a person on claim.
With regards to the Nurse who used to work at Albany Memorial Hospital, Cigna used the change of definition of disability as the reason to deny her claim. However, Cigna’s conclusions were blatantly wrong as there was no way that the former Nurse had the physical capabilities of performing any occupation for the rest of her life.
Cigna’s Denial
As justification for its denial, Cigna relied upon file reviews by its own employees. You read that right. Cigna did not have the Nurse seen by any doctor or medical professional. Cigna did not even have an outside/“independent” doctor perform a review of the Nurse’s medical records. All Cigna did was have its employee Medical Director and Claim Manager perform a review of the Nurse’s medical records. Thus, each of the people that Cigna relied upon to deny the claim had one thing in common: They were employees of Cigna and thus possessed an inherent bias in favor of the insurance company. These employees felt justified in disagreeing with the Nurse’s treating physicians who not only evaluated and treated her, but also supported the fact that the Nurse could no longer work at any occupation. Yes, these employees believed they had a better understanding of the Nurse’s conditions despite never evaluating her and not even laying eyes on her. It was what we call a purely “paper” review.
Dell Disability Lawyers Gets Involved and Files an Administrative Appeal
In addition to ordering updated medical records and gathering support from the many treating providers, Dell Disability Lawyers also had our client evaluated by a physical therapist who conducted a Functional Capacity Evaluation (FCE). The results of the FCE showed that our client had a physical demand capacity of less than sedentary work. Using this information, an appeal was timely filed. The appeal clearly pointed out the objective evidence which showed our client had the diagnoses she was complaining of. It also highlighted the years of support of the treating physicians. Lastly, it gave the results of the FCE. With this appeal, Cigna had no choice but to reapprove the claim.
Claim is Re-Approved
Roughly 3 months after the administrative appeal was filed, Cigna reinstated our client’s long term disability benefits. She is happy to be back on claim and she knows that Dell Disability Lawyers will do whatever it takes to keep her on claim through the maximum benefit period allowed under the policy.
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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Answered Questions by Our Lawyers
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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 >
Q: Do I have a case for STD? I was denied twice because a) I hadn't been a fulltime employee for 6 months and b) I had ben on FMLA since Febury.
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 >
Q: How can I appeal Cigna's decision if there are no written communications explanation the reasons for claim termination?
A: Tret, Cigna will be required by law to provide you with a written denial letter setting forth its reason for t... Read More >
Q: Is there a process for appeals not being responded to in the time given? Also, how do I access my records?
A: SB, ERISA provides 45 days to render a decision on appeal with the possibility of a 45 day extension- basicall... Read More >
Q: Is it worth is to go to court over $2500?
A: Mark, If you have no additional appeals your only option would be to find representation to file a federal law... Read More >
Q: How long will it take Cigna to get back to me? Will my military retiree pay be held against my policy 60%? Will Cigna exploit the disparity in the medical community over my illness?
A: Craig, Unfortunately it can sometime take up to 45 days to receive a decision from Cigna as to your entitlemen... Read More >
Q: Do I have any options to void an agreement I signed? Can Signa offset my SSDI benefits?
A: Donna, I do not know if you would have any avenues to void the agreement you signed. Regardless of agreeing th... Read More >
Q: Can I sue Cigna even if they do end up paying me?
A: Linda, If your policy is governed by ERISA you will need to go through the administrative appeal process prior... Read More >
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Trinity Health Care Registered Nurse wins Cigna long term disability Appeal
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A strong understanding and presentation of the duties of your occupation is essential for securing disability insurance benefits.
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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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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.