CIGNA overturned previous denial of waiver of life insurance premiums
Author: Attorney Jay Symonds
Our client was the husband and beneficiary of Ms. S, who formerly worked as a registered nurse for a regional Healthcare System. In January 2016 a number of medical issues, including cerebrovascular constriction syndrome, vasomotor headaches, unspecified neurocognitive disorder, chronic fatigue, and chronic pain syndrome forced Ms. S to stop working and submit her claim for disability benefits under her employer’s long-term disability (LTD) policy, which was funded and administered by CIGNA. Her claim was approved and paid until her death. At the same time Ms. S applied and was approved for the Life Waiver of Premium benefit which allowed her to maintain the life insurance coverage and waived the payment of premium for as long as she remained totally disabled. Under the policy’s LWOP provision, she would be considered totally disabled if, for the first 9 months, she was unable to perform the material and substantial duties of her regular occupation. Thereafter she would be disabled is she was unable to perform all of the material duties of any occupation she was qualified to perform.
After approving Ms. S’s claim for the first 9 months, CIGNA denied continued LWOP coverage alleging “Ms. S is transferable to other occupations and no longer meets her Policy’s definition of disability.” Unfortunately, in October 2017 while her initial LWOP appeal was pending Ms. S passed away. The appeal was approved for a closed period ending in May 2017 she was denied coverage at the time of her death in October 2017. After receiving the denial, Ms. S’s husband 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. S’s ERISA appeal with the assistance of his appeal team.
The LWOP 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. In particular, the appeal addressed the fact that, CIGNA’s medical reviewer (a) confirmed Ms. S had co-limiting psychiatric conditions complicated by severe fatigue; (b) agreed with Ms. S’s treatment providers opinions and acknowledged that they were well supported by medically acceptable clinical diagnostic techniques; and, most importantly (c) she was limited to just 4 hours per day, 3 days per week of functional activity. Accordingly, there was no reasonable basis on which to claim that Ms. S was capable of any occupation requiring full time or part time sedentary work with reasonable continuity on a regular and sustainable basis. In addition, the appeal relied on the opinion of an expert vocational consultant who concluded the Transferable Skills/Occupational Analysis completed by CIGNA was not valid or reliable because it lacked any supporting evidence that there is a labor market for individuals limited to working no more than 3 days per week for 9-12 hours maximum.
Less than six weeks later, and after reviewing both appeals and hundreds of pages of exhibits and medical records, CIGNA overturned its decision to terminate the LWOP benefit and reinstated Ms. S’s life insurance coverage. Two weeks after the overturn, CIGNA paid out the full life insurance benefit to Ms. S’s husband/beneficiary. Feel free to call our disability attorneys for a free consultation regarding any matter relevant to your disability claim.