Former Aegon USA employee suffering with multiple sclerosis sues CIGNA for denial of disability insurance benefits
A recent disability insurance lawsuit filed at the District Court for the Eastern District of Wisconsin can serve as an eye opener to the kind of claims handling practices that CIGNA will employ in order to evaluate a CIGNA disability claim. In L. v CIGNA Life & Health Insurance/Life Insurance Company of North America, the plaintiff filed a lawsuit under the Employee Retirement Income Security Act of 1974 (ERISA) through her disability lawyer to try and recover long term disability (LTD) benefits which she was and is legitimately entitled to. Allegedly, CIGNA Life had been relentless in denying the critically ill woman her claim despite the overwhelming medical evidence supporting her claim.
The Facts of the CIGNA disability Claim Denial
The plaintiff was formerly a group underwriter working for Aegon USA, Inc. On October 1984, she participated in a group long term disability insurance policy that was issued by the Life Insurance Company of North America (LINA) which is now merged with CIGNA. The plaintiff suffered from:
- Cervical Radiculopathy
- Chronic pain
- Greater trochanteric bursitis
- Impaired vision
- Muscle spasticity
- Muscle weakness
- Multiple Sclerosis (MS)
On Short Term Disability:
On September 1st 2009, the plaintiff visited her attending physicians. After evaluating the plaintiff the doctor wrote a note stating that “the plaintiff will be out of work for at least 4 – 6 weeks due to increase in symptoms related to MS. She will be re-evaluated in 4-6 weeks to see if she can return to work.” At the same time, the physician asked that the plaintiff was to go on short term disability on that day as well.
The plaintiff on September 3rd 2009 ceased working and underwent several medical procedures for the treatment of her medical conditions. She was later re-evaluated by her attending physicians on September 29th 2009 who concluded that her “symptoms certainly prevent her from returning to work.” The plaintiff’s attending physicians also stated that the plaintiff was to continue on short term disability. During the same period, the dosages for her medications were also increased by her attending physicians.
The plaintiff continued her treatments for her symptoms which had increased in severity until on December 22nd 2009 her attending physician stated that the plaintiff had “been out of work on short term disability dating to September 1st 2009 “¦ Unfortunately, none of her symptoms have improved since that time”¦ She is incapable of any gainful employment at this time due to painful dysesthesias, fatigue secondary to MS and a subjective cognitive dysfunction.”
Claim for CIGNA Long Term Disability Benefits:
On January 6th 2010, the plaintiff made an application for LTD benefits by way of a telephone call to CIGNA. On the Physical Ability Assessment Form the physician stated that for an 8 hour workday, the plaintiff can only tolerate:
- Sitting: occasionally
- Standing: occasionally, very limited secondary to fatigue
- Walking: occasionally, very limited secondary to fatigue
- Reaching: never, due to weakness and fatigue
- Fine Manipulation: never, due to in coordination and fatigue
- Simple Grasp: occasionally
- Firm Grasp: never, due to weakness
- Lifting: occasionally less than 10 pounds only
- Carrying: occasionally less than 10 pounds only
- Climbing regular stairs: very limited
- Balancing: never, due to decreased balance, in coordination, gait dysfunction
- Stooping: never, due to decreased balance, in coordination, gait dysfunction
- Kneeling: never, due to decreased balance, in coordination, gait dysfunction
- Crouching: never, due to decreased balance, in coordination, gait dysfunction
- Crawling: never, due to decreased balance, in coordination, gait dysfunction
- Exposure to Extreme Heat: never
“Occasionally” in the Physical Ability Assessment Form is defined as being 33% or less than 2.5 hours of an 8 hours workday. In the Physical Ability Assessment form, the physician also stated that “this [patient] is unable to work any [occupation].”
The plaintiff on January 25th 2010 filed a Report of claim for LTD with CIGNA as suffering from cognitive problems associated with MS, fatigue, pain and MS. However, CIGNA on February 16th 2010 denied the plaintiff her claim for benefits. In the letter of denial, it was stated that the denial was based on the document reviews by both CIGNA’s nurse case manager and CIGNA’s medical director even though neither of these individuals examined the Plaintiff. CIGNA never spoke directly with the doctor and instead spoke only to the doctor’s office assistant. The denial letter also stated that the plaintiff was denied disability benefits because the assistant “noted that you are suffering from severe fatigue and could not work. She also noted that you are having an increase in your symptoms, but the symptoms were not an exacerbation of your [MS].”
CIGNA was aware that the assistant was not medically qualified to provide any medical opinions. Yet CIGNA had unreasonably relied on the information or opinions provided by her. It should be noted that by March 30th 2010 the plaintiff was actively taking twenty-two different types of medications for which twenty of them she had to take daily to treat her medical conditions. The medication taken included:
- Antihistamine as needed
- B Complex Plus once daily
- Calcium-Magnesium-Zinc tablet once daily
- Cymbalta 60 mg two times daily
- Decongestant as needed
- Detrol LA 4mg once daily
- Ferrous Gluconate 225mg once daily
- Fish Oil Concentrate 100mg once daily
- Lexapro 10mg once daily
- Lidoderm 5% patch up to 3 patches daily
- Lyrica 150mg 3 times daily
- OXcarbazepine 150mg two times daily
- Prevacid 30mg two times daily
- Red Yeast Rice 600mg once daily
- Rebif subcutaneous injections 3 times a week
- Ritalin 20mg two times daily
- Skelaxin 800mg every eight hours
- Topiramate 25mg two times daily
- TiZANidine HCI 4mg once daily
- Vitamin D 50,000 units once a week
- Zanaflex 4mg three times daily
1st ERISA to CIGNA
On April 13th 2010, the plaintiff submitted to CIGNA with written notice of her appeal of the February 16th 2010 denial. Based on CIGNA’s internal notes, it was revealed that CIGNA’s medical director, Dr McCool stated that “she was not felt to be disabled by Dr Godsall.” This is despite the fact that Dr Godsall was evaluating the plaintiff’s neuropsychological assessment and not the plaintiff’s physical medical conditions. Hence, Dr McCool concluded: “the medical review does not show a physical or functional loss to support the restrictions and limitations for the claimant’s own sedentary level of occupation.”
CIGNA notified the plaintiff on June 2nd 2010 that having completed the review of the plaintiff’s appeal, it was denying her entitlement to disability benefits because “the medical evidence fails to support your inability to perform your sedentary occupation as an Underwriting Manager.”
The June 2nd letter of denial letter also stated that CIGNA’s Medical Director reviewed a March 24th 2010 letter from plaintiff’s doctor that “states his opinion that you are unable to work due to significant fatigue, painful sensations, vision issues and muscle weakness/spasm/decreased balance related to [MS]” and falsely stated that the March 24th 2010 letter from the doctor “goes on to provide work restrictions that are consistent with sedentary work capacity.”
The September 22nd 2010 office visit notes of the physicians also revealed that the plaintiff had been denied LTD benefits in spite of the fact that the doctor had “supplied numerous documentations to support her disability.” The doctor went on to state that the plaintiff “has significant symptoms from her MS that prevent her from maintaining gainful employment.” and that “[it] is a complete mystery to me how they can deny her disability when her medical physicians have documented it so clearly.”
In a November 23rd 2010 letter sent to CIGNA, it can be seen that the plaintiff’s attending physician was clearly frustrated with the actions of CIGNA. In the letter, plaintiff’s doctor stated that “I have previously corresponded in support of plaintiff’s reinstatement of benefits and on March 24, 2010, I wrote a letter explaining the disabling nature of plaintiff’s MS. It is a complete mystery to me that plaintiff’s disability benefits continue to be denied in the face of overwhelming medical documentation supporting her disabling conditions and limitations.”
He also stated “[a]s her treating physician, I have physically examined the plaintiff and followed the progression of her MS for years and as such I am in a position to make the most informed decision about her ability to work. It continues to be my opinion that the plaintiff is completely disabled and is unable to work in any occupation. I respectfully request that you reinstate the plaintiff’s disability benefits.”
2nd ERISA Appeal to CIGNA
On November 29th 2010, the plaintiff submitted her second appeal to the denial of LTD benefits by CIGNA. CIGNA on December 2nd 2010, wrote to the plaintiff through their attorney and advised her that she should “forward any additional information you wish to have reviewed on appeal to us on or before December 23rd 2010 … If you have submitted all the pertinent information you wish to be reviewed for your client’s appeal, please contact the above listed phone number to notify us that you will not be submitting additional information.”
The plaintiff never contacted CIGNA in response to the December 2nd 2010 letter to advise it that she had “submitted all the pertinent information she wished to be reviewed” on appeal. However, she submitted additional witness statements to support her appeal on December 23rd 2010. The plaintiff however, was not aware that CIGNA was trying to preempt her appeal. CIGNA had on December 21st 2010, prior to the December 23rd 2010 deadline established by CIGNA above, denied the plaintiff her appeal and posted their reply which the plaintiff only received on January 3rd 2011.
The December 21st 2010 letter of denial mentioned that the plaintiff’s medical records were reviewed by CIGNA’s medical director and stated that “[a] review of the medical information fails to provide consistent medical evidence of a severe, functional impairment that would preclude the plaintiff from performing all the material duties of her regular occupation “¦ Although the doctor has provided restrictions of no work, at this time no documentation has been provided to support those restrictions.”
Reopening of Second Appeal
On January 5th 2011, the plaintiff demanded that CIGNA reopen her appeal and analyzed the additional witness statements that she submitted on December 23rd 2010, in accordance with the terms of CIGNA’s December 2nd 2010 letter. CIGNA on January 6th 2011 responded that “our office reviewed the information submitted on December 23, 2010. Unfortunately this new information does not change our prior determination of plaintiff’s Long Term Disability appeal.”
Following the denial of both appeals submitted to CIGNA, the Plaintiff was left with no choice and had to file a lawsuit in Federal Court seeking reinstatement of her disability benefits. As one of the largest provider of disability insurance coverage in the U.S, the CIGNA Life & Health Insurance (CIGNA Life) has the ability to make claimants fight for their entitlement to disability beenfits in the Courts after years of dragging their feet, causing anxiety to disabled claimants who really are in need of the disability benefit payments.
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