Life Insurance Company of North America (CIGNA) overturned previous denial of long term disability benefits for New Jersey Account Manager
Author: Attorney Jay Symonds
Our client, Mr. W, formerly worked as an Account Manager for a large entertainment Company. In May 2015 a number of co-morbid physical and psychiatric conditions and ailments forced Mr. W to stop working and submit his claim for disability benefits first under his employer’s short term disability (“STD”) Policy then continuing under his employer’s Long-Term Disability (“LTD”) Policy both benefits were administered and funded by CIGNA. Under both of his employer’s disability policies Mr. W would be considered totally disabled if he was unable to perform the material duties of his regular occupation, which was defined as the occupation he was routinely performing when his disability began.
After paying Mr. W for more than 7 months under the LTD Policy, CIGNA denied further LTD benefits on the basis that he allegedly no longer met the policy definition of disability. Specifically, Prudential determined that “the medical records on file do not provide evidence of continuing functional deficits that would prevent you from performing your occupation.” After receiving the denial, Mr. W contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in CIGNA’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. W’s ERISA appeal with the assistance of his appeal team.
The LTD appeal 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 denial. The appeal next addressed the fact that the available medical information confirmed that Mr. W suffered severe neurological injuries from a motor-vehicle accident after which he began experiencing extreme balance issues and his thinking became “fuzzy.” Mr. W’s neurological symptoms included serious problems speaking fluently, and he struggled to find correct words. Mr. W was examined by neurologist who conducted a CT scan and concluded that Mr. W suffered severe neurological deficits from the Traumatic Brain Injury (TBI) he suffered in the accident. Along with the cognitive and neurological difficulties Mr. W also suffered from serious orthopedic problems and was unable to walk any meaningful distance, his gait was extremely unsteady, and he required a cane. The appeal also addressed CIGNA’s in-house medical review and established that CIGNA’s reviewer incorrectly and unfairly determined that Mr. W was a malingerer and therefore suffered no restrictions or limitations as a result of his chronic and debilitating illnesses. Yet, the record evidence clearly establishes that each of the statements on which the reviewer based her determination was either pure speculation or contradicted by the available medical information. Accordingly, the reviewer’s opinions were fatally flawed and it was unreasonable for CIGNA to rely on them in support of its denial of LTD benefits.
Five months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records as well as the expert reports, CIGNA overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. W’s LTD claim. Attorney Symonds continues to represent our client to best ensure that CIGNA will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.