Cigna overturns decision to terminate benefits of Claimant suffering from Multiple Sclerosis
Author: Attorney Rachel Alters
Cigna terminated long-term disability benefits as it determined that the claimant was no longer unable to perform the material and substantial duties of any gainful occupation. However, the medical and occupational documentation clearly established that due to physical and cognitive limitations stemming from her diagnosis of Multiple Sclerosis (MS), the claimant was unable to perform the material duties of her regular occupation as a Technical Writer or any occupation for which she is or may reasonably become qualified based on education, training or experience. The claimant is a 45 year old female who was forced to go out of work on disability on August 8, 2015 due to increasing difficulty with chronic relapsing MS in spite of multiple treatment efforts. Her symptomatology include but is not limited to multiple episodes of optic neuritis, vertigo, frequent urinary tract infections, muscle/back aches, neuropathy, and difficulty with balance. In addition, she also suffers from profound fatigue and cognitive difficulties which have progressively worsened.
Cigna Approves Benefits under the “Own Occupation“ Definition
Prior to going out on disability, she was employed as a Technical Writer for BSH Home Appliances Corporation. According to her job description, she worked under the engineering department and was responsible for providing the documentation necessary to allow efficient and effective servicing of products when service is required. Although the exertional demand of the occupation was deemed to be sedentary in nature, the job description reflects that local travel was material to the role. In addition, a high degree of focus, concentration, and attention to detail is material to performing her occupation successfully. She applied for long term disability insurance benefits under her policy with Cigna as her condition had progressed to the point where she was no longer physically or cognitively able to perform her occupational duties effectively. Upon review of the medical records, Cigna agreed that her condition was of such severity that it would in fact prevent her from performing the material duties of her occupation as a Technical Writer; therefore, in a letter dated May 16, 2016, Cigna approved her claim for Long Term Disability benefits as of her effective date of disability of August 8, 2015.
Cigna Determines Claimant is Not Able to Perform Duties of Any Occupation
Approximately a year later on May 25, 2016, Cigna found that the severity of her condition would not only render her disabled from her own occupation, but also from any occupation for which she may reasonably become qualified based on education, training, or experience. Hence, Cigna continued her LTD benefits and also approved her for Waiver of Life Insurance Premiums benefits which she would only be eligible for if totally disabled and unable to engage in any occupation.
Out of the Blue, Cigna Terminates LTD Benefits Claiming She Can Now Return to Work Full Time
The claimant experienced no significant improvement in her condition and given the progressive nature of her diagnosis improvement was highly unlikely. Although she may have experienced some good days, characteristic of the remitting/relapsing nature of her Multiple Sclerosis, the ongoing frequency, intensity, and duration of her symptomatology would never allow for sustained work activities 8 hours a day, 40 hours a week – even at a sedentary level. It is unconscionable that Cigna would terminate both her LTD and waiver of premium benefits, approximately a year after deeming her totally disabled and unable to engage in any occupation, on the “purported” basis that she was “now” capable of performing the material duties of her occupation. Cigna’s decision suggests that she miraculously recovered from her diagnosis of MS which was not only unfounded but illogical in light of the medical evidence and the very nature of her medical diagnosis. Of significant concern, Cigna did not as much as request a neuropsychological evaluation to assess her cognitive ability, although such examinations are provisioned for in the Policy and given Cigna itself noted in April of 2016 “Employee with her major multiple sclerosis complaints continued to be memory loss and cognitive decline…” Clearly, Cigna’s decision was arbitrary and capricious, demonstrating an abuse of any purported discretion they may have under the policy.
Furthermore, the claimant’s treating physician confirmed based on the medical evidence to include her diagnostic and laboratory findings that there was evidence of progression of her Multiple Sclerosis, and her diagnosis was upgraded from remitting/relapsing MS to Secondary Progressive MS (SPMS). Clearly, Cigna failed to meet its burden of proving that the claimant was no longer disabled under the terms of her policy. Cigna ignored the clinical evidence to the contrary to include its own prior reasoned assessment and determination supporting disability. Cigna provided absolutely no explanation for its change in opinion after deeming her disabled and unable to engage in any occupation in May of 2016, less than a year prior to its adverse decision.
After a lengthy appeal was submitted by Attorney Alters on behalf of the claimant, Cigna overturned it’s determination to terminate her benefits, paid her back benefits and put her back on claim. Attorney Alters will continue to manage her claim to help ensure that Cigna does not cut her off again.
If you have been denied disability benefits by Cigna or any other disability insurance company, please do not hesitate to contact Attorney Rachel Alters at Dell & Schaefer for a free consultation.