Our client, Ms. K, formerly worked as an IT Procurement Specialist for a large international technology company, which required “sedentary” work functional capabilities. In April 2015 a number of psychiatric issues, including the debilitating co-morbid effects of anxiety, depression, alcohol dependence and PTSD forced Ms. K to stop working and submit her claim for disability benefits first under his employer’s short-term disability (STD) policy, administered by Sedgwick, and then continuing under its long-term disability (LTD) policy, administered by CIGNA. Under her employer’s disability policies Ms. G 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. K for the maximum benefit period under the STD policy, which relied on a definition of total disability nearly identical to that in the LTD policy, CIGNA denied LTD benefits on the basis that Ms. K did not meet the policy definition of disability. Specifically, CIGNA stated that “the presence of severe symptoms of mental illness or a functional mental impairment which would prevent [her] from doing [her] own occupation from her date of disability through present were not evident.” After receiving the denials, Ms. K contacted Dell & Schaefer and discussed her 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 Ms. K’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 and significant inconsistencies with its medical reviewer’s findings. The appeal also addressed the fact CIGNA’s own claim file confirmed that it held Ms. K’s primary treatment provider to an unreasonable and unfair deadline to provide records and information; based its decision on a medical opinion that clearly recognized the possibility of a different outcome had all relevant medical records been obtained and reviewed; failed to send the relevant supplemental records to its medical consultant for her review, opting instead for reviews by in-house nurse consultants; and, finally, failed to send Ms. K’s treatment provider’s written responses to questions to its medical consultant when they clearly addressed many of the concerns outlined in the consultant’s review.
Approximately six weeks later, and after reviewing each appeal and hundreds of pages of exhibits and medical records, CIGNA overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. K’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.