Our client, Ms. C, formerly worked as a Senior Personal Banker for a large national bank, which required “light” work functional capabilities. In July 2016 a number of medical issues, including the debilitating co-morbid effects of Sternal Osteomyelitis, Arthritis, Depression and PTSD forced Ms. C to stop working and submit her claim for disability benefits first under her employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were administered by CIGNA. Under her employer’s disability policies Ms. C would be considered totally disabled if she was unable to perform the material duties of her regular occupation. Her regular occupation was defined as the job she performed at the time disability began but as that occupation was normally performed in the general labor market and not as it was performed for her specific employer.
After paying Ms. C for ten weeks under the STD Policy, CIGNA denied further STD benefits on the basis that she allegedly no longer met the policy definition of disability. Specifically, CIGNA stated that “the information provided did not demonstrate or clarify functional impairment that would prevent [her] from being able to work at this time.” Ms. C appealed this decision and simultaneously filed a claim under the LTD Policy. Both were subsequently denied. After receiving the denials, Ms. C contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in CIGNA’s denial letters and in the evidence it relied on and agreed to prepare and submit Ms. C’s ERISA appeal with the assistance of his appeal team.
Although filed separately to ensure a full, fair and independent review of both claims, the substance of both appeals addressed all of CIGNA’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of CIGNA’s denials and significant inconsistencies with its medical reviewer’s findings. Specifically, the appeal addresses the fact that CIGNA’s two in-house medical records reviewers ignored and/or disregarded an independent Functional Capacity Examination (FCE) ordered by Ms. C’s primary treatment provider in an effort to provide an objective assessment of Ms. C’s functional capabilities. The FCE established that Ms. C could not perform even a sedentary occupation. The medical reviewers also applied an incorrect policy standard to Ms. C’s claim by requiring that she establish a “complete functional loss.”
Approximately six weeks later, and after reviewing each appeal and hundreds of pages of exhibits and medical records, CIGNA overturned both decisions to terminate benefits, paid full STD back benefits and reinstated Ms. C’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that CIGNA will not terminate her benefits again. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.