CIGNA long term disability denial is reversed by New York Federal Judge

Steven Alfano was a wage and salary manager when he was injured in a car accident in May 1996. Though he returned to work after he recovered from his acute injuries, he still suffered from back pain and residual weakness in his left leg. Because of this he continued to see Dr. Michael Alexiades, an orthopedic surgeon.

His back condition got worse over time. By May 2000, it became apparent that he would not be able to continue working even though his position was sedentary. He could not sit for more 1/2 to 2 hours before he had to resort to laying down or sitting in a reclined position. Dr. Alexiades gave Alfano his official opinion that he should stop working on June 5, 2000. He followed his doctor’s recommendation.

Alfano had participated in group long-term disability benefit plan his employer, Cornell University Weill College contracted for with CIGNA Life Insurance Company (CIGNA). The plan stipulated that Alfano had to be disabled for 180 days before he could apply for benefits.

Realizing that he was indeed not going to be able to work again, Alfano applied for Social Security Disability Income (SSDI) benefits immediately, then waited as required by the plan to apply for his long-term disability benefits from CIGNA. He applied for disability benefits a few days before the 180 days waiting period ended. CIGNA denied his application for disability benefits, even though the decision to deny his claim occurred more than six months after he had to leave work.

Alfano hired a long-term disability attorney and appealed promptly. CIGNA upheld its denial once again, claiming Alfano had not fulfilled the 180 day waiting period. So he waited a full year, until April 2002 before he appealed the denial a second time. He added the most recent medical records to the multiple medical reports and tests provided with his initial application. All the evidence, doctor’s reports, MRIs and EMGs demonstrated that his condition had not improved over the intervening year.

Social Security found him disabled shortly after he filed his second appeal. So he informed CIGNA of this fact as well on September 13, 2002. It took the long-term disability company almost three months to respond, and when the claims handler contacted him, it was to inform Alfano that they needed to consult a health care professional with the appropriate training and experience.

Dr. David Trotter, the orthopedic surgeon CIGNA sent his file to, found that the evidence proved that the stenosis and nerve root impingement revealed in his MRIs and resulting inability to sit for long enough to work a full day effectively rendered Alfano disabled from his own occupation as a wage and salary manager. This finding played a key role in the decision to reverse its initial decision and to begin paying Alfano long-term disability benefits. The notice informed Alfano that retroactive payments would go to December 3, 2000 just two days after the day he filed his claim.

At the two year mark, CIGNA tried to invoke an “any occupation” evaluation of Alfano’s qualifications for disability. Alfano’s disability attorney quickly notified the disability insurance company that his policy did not have an “any occupation” clause. CIGNA corrected this understanding while making it clear that Alfano could only maintain his benefits by continuing to prove he qualified under the “own occupation” standard.

This involved regular reports from his treating physicians. One such report submitted in October 2004, convinced CIGNA that his condition had improved, even though subsequent communications corrected the misunderstanding that led to inaccuracy in the filling out of the form. Based on this one report that appeared to say that Alfano could now sit, walk and stand for up to 2-1/2 to 5 hours of an 8-hour workday, CIGNA terminated his long-term disability benefits.

From that point on, it seemed that nothing Alfano produced as evidence of his continuing disability had any effect. CIGNA ordered three separate transferable skills analyses (TSAs). Each one found that he could work in his own occupation. CIGNA ordered a functional capacity evaluation (FCE). The summary found he was capable of sedentary work, even though a quick read of the actual evaluation demonstrated the opposite. Two physicians, hired by CIGNA, found that his medical records coupled with the FCE failed to support his continuing disability. For a detailed pre-lawsuit history of Mr. Alfano’s case please see the article CIGNA terminates disability insurance benefits as claimant’s back condition gets worse.

After three appeals, Alfano had no choice but to file an ERISA lawsuit against CIGNA for wrongful denial of disability benefits. Both Alfano’s disability attorney and CIGNA’s attorneys agreed that the correct standard with which to review CIGNA’s decision was de novo. This standard allows the Court to look at a disability plan administrator’s decision with a more critical eye. The Court has the right to look at the evidence and evaluate whether the plan administrator’s decision was right, not just unreasonable.

Alfano’s disability attorney did not present any evidence that showed good cause for adding anything to the disability plan’s administrative record, so this would be the evidence that the Court would consider. The disability attorney had all the evidence necessary right in the record to demonstrate that CIGNA had made the wrong decision.

It was vital in this case for Alfano’s disability attorney to prove under ERISA that he was unable to perform sedentary work, as this was the classification the plan gave his occupation as a wage and salary manager. The question before the Court was this. Had Alfano met his burden to prove to the disability benefit plan that he was still disabled under the plan, before his benefits were terminated? Had a significant change in his condition warranted CIGNA’s decision to terminate his benefits? If the Court found that Alfano’s condition was the same or worse than when he was found disabled initially, terminating his benefits would weigh against CIGNA.

Indeed, this is exactly what a review of the medical record demonstrated. Alfano had submitted extensive evidence that he was disabled and continued to remain so. While two physicians were his primary care providers, no less than four additional neutral physicians had evaluated him and found him severely limited by L5-S1 radiculopathy. His need to take heavy doses of narcotics to manage his pain was also well documented. He had submitted to multiple MRIs which showed his condition worsening.

The functional capacity evaluation ordered at CIGNA’s request also supported his inability to work an 8-hour day. He was unable to perform many of the tests due to his inability to maintain control of his legs. The lifting test had to be stopped. He had to lie down numerous times during the test.

Despite this extensive medical support, CIGNA claimed that under ERISA it had no obligation to give weight to Alfano’s medical evidence. The Court disagreed. ERISA requires long-term disability plans to provide a clear rational for rejecting a treating physician’s opinion before it can discredit evidence a claimant has presented. The Court could not order CIGNA to give more weight to Alfano’s doctors, but it could require CIGNA to show just cause for ignoring the evidence.

The Court recognized that CIGNA didn’t have to order an independent medical evaluation. File reviews were adequate. Yet, because the Court was reviewing Alfano’s claim de novo it could consider whether the long-term relationship between Alfano and his physicians would make their opinions of more value than that of a doctor just reading his file. When the length of his relationship with at least six doctors was combined with the fact that eight separate physicians had concluded that he was disabled, including one hired by CIGNA. The Court would give this evidence substantial weight in the decision-making process.

Then there was the finding by Social Security that Alfano was disabled to consider. CIGNA tried to argue that it wasn’t bound to agree with a SSDI decision. Yet, the Court found that Social Security had used an even stricter standard for approving Alfano’s benefits – his inability to work in any occupation. The Court found it inconsistent for CIGNA to seek to benefit financially from Alfano’s receipt of SSDI benefits, yet not demonstrate how the requirements of the plan differed from those of Social Security. The Court determined that the Social Security decision should also bear substantial weight in its decision-making process.

The Court found that CIGNA’s presentation of vocations it claimed Alfano could work in was argued against by his medical record. Not a single job would have accommodated Alfano’s primary limitations – an inability to sit more than 2 to 2-1/2 hours per day or to walk for more than a total of 2-1/2 hours per day. The Court cited to another long term disability case in which they stated that “The ability to sit for a total of four hours does not generally satisfy the standard for sedentary work.”

The main problem with all three TSAs was the fact that they failed to consider all of the record. The last two TSAs obviously relied on the first page summary of the FCE performed on July 26, 2005. Unfortunately, this summary bore little resemblance to the information in the rest of the FCE. While the summary stated that Alfano was “functioning safely at a sedentary level for an eight hour period according to N.Y. Department of Labor Standards,” numerous contradictions to the statement appeared within.

The FCE noted that Alfano “was unable to stoop, kneel, crouch, or crawl.” This was due to decreased range of motion as well as weakness and the inability to prevent his lower extremities from buckling beneath him. The clinical data obtained during the evaluation did not support his ability to tolerate sitting for more than “10 to 15 minutes without a drastic change in position.” The tester stated that he had to lie down frequently during the test to alleviate his symptoms.” The Court found it inexcusable that CIGNA did not question the validity of the summary when the data more clearly supported the opinions of his treating physicians that he could not sit for more than 2-1/2 hours a day.

Such a careless reliance on the summary page of an FCE was not new to the Court. In Rappa v. Connecticut General Life Insurance Company, the Court found that a disability insurance plan is irresponsible when it depends upon a summary page instead of evaluating the full contents of an FCE. CIGNA could not argue that it had reached a correct decision when it ignored portions of the FCE that contradicted the summary.

Before reaching a decision, the Court had to also consider whether CIGNA’s dependence on the opinions of physicians it chose to review Alfano’s files was a credible reason to terminate Alfano’s benefits. Had the opinions reached by these reviews adequately and credibly presented a rebuttal to the findings of Alfano’s physicians?

One physician claimed that the medical evidence presented by Alfano failed to support his inability to sit for prolonged periods and his need to change positions frequently. This conclusion ignored MRIs, an EMG, and positive leg raise tests which supported the conclusion of several physicians that his ability to sit for more that 2-1/2 hours per day. It also ignored the findings of the FCE which confirmed the same conclusion.

Every other expert’s findings also leaned heavily upon the summary page of the FCE. Some stated that Alfano’s physicians had provided vague responses, a charge the Court found unfounded.

After reviewing all the evidence, the Court found that CIGNA’s position that Alfano’s condition had improved, making him capable of returning to his own occupation, was not grounded upon fact. In fact, the medical evidence suggested that his condition was continuing to deteriorate. CIGNA had wrongfully terminated Alfano’s benefits.

CIGNA argued that the Court should remand Alfano’s claim back into the disability company’s control. The Court refused to do this. Such a decision would send a message to disability insurance plans that they can continue to be careless and avoid the consequences of not abiding by the rules established by ERISA.

CIGNA’s termination had been improper. A clear decision granting Alfano’s disability attorney’s motion for summary judgment was the only appropriate remedy. The Court ordered CIGNA to reinstate Alfano’s long-term disability benefits retroactively and to continue making payments until he either ceases to be disabled or reaches 63 years of age.

Attorneys Dell & Schaefer did not represent Mr. Alfano as it related to his claim for disability benefits.

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