Prior to contacting Dell & Schaefer our client had already endured a long, frustrating battle with Cigna. At the age of 63 she had expected that her career as an Executive Director for Independent Living Facilities would end as she neared Social Security Retirement Age. However, her health had another plan for her. For some time she had heroically continued to try to work despite suffering from a multitude of medical conditions, including: Lupus, Fibromyalgia, Connective Tissue Disorder and Rheumatoid Arthritis. Despite her best efforts the demands of her job and her responsibility for the overseeing of multiple facilities began to take a toll on her body. As her pain and symptoms increased she had no choice but to turn to the short term disability policy that her employer had provided. Like many people who file a claim for disability benefits under their employer’s Group Disability Policy, she had no idea how hard a fight it would be.
The First Cigna Denial Of Short Term Disability Benefits
In November 2011, she filed her application for short term disability benefits with Cigna. By January 11, 2012, she received notice that her claim was being denied due to what Cigna claimed to be a lack of medical information provided that demonstrated an inability to perform the duties of her regular occupation. This, despite the fact her doctor had consistently and staunchly voiced his opinion that she was not able to perform the duties required of her occupation. What made this an even tougher pill to swallow is the fact that Cigna ignored her doctor’s medical opinion in favor of the opinion expressed by its in-house nurse.
On her own, our client filed an appeal of this decision. Submitted with the appeal was another lengthy statement drafted by her doctor that once again detailed her multiple medical conditions and expressed his opinion that based on her medical conditions she would not be able to perform the duties of her occupation. Cigna this time decided to not cut corners and rely solely on the opinion of its nurse case manager, and instead used an internal medical director to review her claim. It was with little surprise that based on the medical director’s review Cigna, in April 2012, advised our client they were upholding the denial of her appeal, stating that the “[I]nformation provided did not support severity of condition to support functional impairment.”
The Second Appeal of A Cigna Short Term Disability Denial
Disheartened and tired from fighting with Cigna, our client contacted Attorneys Dell & Schaefer to handle the filing of her second (and final) appeal. Attorney Stephen Jessup was assigned to her case and worked with her to prepare this incredibly important final appeal. This appeal represented the last opportunity she would have to provide information sufficient to establish in Cigna’s mind that she would not be able to perform the duties of her occupation. Attorney Jessup started the process by obtaining a copy of the claim file and conducting a thorough review of same. It was quickly realized that Cigna did not even have a copy of her job description on file, nor had Cigna conducted any type of vocational review to better understand what our client’s occupation entailed. Obviously, this begged the question of how could Cigna assert she was not prevented from performing her occupation when they didn’t have any idea what her occupation actually entailed? Furthermore, it was discovered that Cigna did not have many of our client’s medical records; records that helped provide a complete picture of our client’s medical conditions and their impact on her ability to work.
Attorney Jessup coordinated testing for our client to undergo, which helped provide quantifiable information to substantiate physical restrictions and limitations. Additionally, he reached out again to her long time treating physician to prepare a statement that was specifically crafted to undermine the opinions of Cigna’s medical reviewers. Armed with additional proof of disability, Attorney Jessup submitted our client’s final appeal for short term disability benefits and requested a contemporaneous review of her claim for long term disability benefits.
The Decision to Reverse the Cigna Denial
Based on the overwhelming body of medical information and unable to hide behind insufficient and incomplete reviews of our client’s file, Cigna reinstated her claim for disability benefits through the entire period of short term disability. Currently, Cigna is conducting its review of her entitlement to Long Term Disability benefits.
Every day people file for short or long term disability benefits through policies provided by their employers. For those whose claims are denied very little information is provided to explain the importance of the Appeal process and the ramifications if one fails to adequately prepare same. Failure to provide information necessary to establish entitlement to disability benefits in an Appeal could result in a claimant from being barred from ever providing same. It is imperative that before you file an ERISA appeal of a disability claim denial that you speak with an attorney so you can understand your rights. Please feel free to contact Attorneys Dell & Schaefer via phone or through our online contact form for a free consultation.