Court Criticizes Lina For Failing to Perform Independent Examination
Disability Insurance companies are criticized often for failing to perform independent medical evaluations and instead relying exclusively on file reviews performed by in house doctors. The tendency to perform reviews in this fashion is more common with some carriers than others. Such is the case with Life Insurance Company of North America (LINA) also known as Cigna.
In Guest-Marcotte v. Life Insurance Company of North America the 6th circuit court of appeals criticizes LINA for doing this very thing.
This case involved a denial of benefits to a claimant suffering from a rare condition known as Ehlers-Danlos Syndrome (EDS) Type 3, which is characterized, most notably, by its tendency to cause joint hypermobility. The common symptoms include joint hypermobility, affecting both large and small joints; soft, smooth skin that may be elastic or stretchy and bruises easily; and chronic musculoskeletal pain.
After filing her claim for symptoms caused by EDS, Ms. Guest-Marcotte’s claim was denied by Cigna following a file review by Cigna’s in-house physician. Her appeal was also denied despite the submission of additional evidence following a review by the same nurse case manager who reviewed the claim initially and a review by another physician. The claimant also exercised her right to a second administrative appeal which was similarly denied.
Ms. Guest-Marcotte filed suit against Cigna but lost after a magistrate judge issued a report and recommendation finding that Cigna had not acted unreasonably, and the district court adopted the report.
On appeal to the 6th Circuit Court of Appeals, the decision was reversed. The critique began and focused on Cigna’s failure to exercise its option to conduct a physician examination. The court pointed out that multiple doctors had provided reports that the plaintiff could not drive, sit still or concentrate due to severe pain and so “it was not reasonable for LINA to brush aside her claims of debilitating pain without first performing a physical exam.” The court also pointed out that since the diagnosis of EDS was accepted without question, if Cigna disbelieved the claimant, how could it be logically possible to deny the treating doctors’ observations in the absence of contrary observations?
Since the diagnosis was undisputed, and the condition is known to cause frequent joint dislocations and chronic pain, the court found LINA’s denial without conducting a physical examination arbitrary and capricious. The court remanded the case back to LINA so it could “conduct a deliberate and principled review of Guest-Marcotte’s claim.”
While this claimant was successful in getting her claim remanded back to Cigna for an additional review it should be noted that Cigna already performed three separate reviews of Ms. Guest-Marcotte’s claim and the court is simply giving Cigna another opportunity to review again, albeit with instructions to perform a physical evaluation of Ms. Guest-Marcotte.
Just as important is the fact that the court distinguished this case from other cases where it is difficult to diagnose the condition, such as fibromyalgia or back pain. Courts have upheld claim denials in the 6th circuit as well as others where the claims administrator did not perform a physical evaluation and relied primarily on in house file reviews.
This case was not handled by our office, but we think it can be beneficial to those struggling to obtain long-term disability benefits. If you have any questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free case evaluation.
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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 >
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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 >
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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.
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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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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.
Do I have to come to your office to work with your law firm?
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.