CIGNA overturns decision to terminate benefits of telephone sales representative with severe degenerative disc disease
Author: Attorney Rachel Alters
CIGNA improperly terminated claimant’s disability benefits stating that the information in the claim file did not support a continued impairment to preclude her from performing her own occupation. It was apparent that CIGNA failed to consider relevant information which supported that the claimant was in fact, precluded from performing the material duties of her regular occupation.
In appealing the termination of benefits, Attorney Rachel Alters argued that CIGNA was arbitrary and capricious in terminating the claimant’s benefits when her medical records and treating physicians’ opinions were clear that she was incapable of performing full-time sedentary work. CIGNA’s disability determination was based on a selective review the claimant’s medical records. Despite the fact that the STD/LTD Plan permits CIGNA to conduct an Independent Medical Examination or Functional Capacity Evaluation, CIGNA chose not to perform any such evaluation. CIGNA’s decision not to perform any examination is significant because a dispute clearly existed between the opinion of her treating physician and that of CIGNA’s reviewing medical consultants.
The claimant’s treating physician documented that:
She had a poor outcome from her surgery and continued to be symptomatic with back pain. It was carefully explained to her that she has a collapsing deformity at the adjacent level L5-S1 and that pelvic rotation will be difficult, particularly sitting for any period of time on a regular basis. She should only be sitting for one hour at a time and then doing stretching exercises. She is incapable of doing any lifting. It was initially stated that she could lift up to 20 lbs., however, but now she is not to lift greater than 5 pounds. There is concern that a job sitting at a computer with lumbar spine hyperextension is impossible given the complexity of her spinal fusion and the residual deficits. She previously underwent injections and is reluctant to be put on high dose steroids due to possible complications and side effects. She was placed on very strict restrictions of no gainful employment where sitting is a regular part of her duties. She can sit for 30-35 minutes at a time and then would have to stand up. She will need the ability to lie flat at least every 2-3 hours given the complexity of her spinal condition. Without these limitations, she would have to be on high dose narcotics/steroids which are harmful and cause her side effects. She continues on NSAIDs which provide mild relief. She is unable to perform secretarial type duties as she can only perform computer work with sitting for only a minimal time period.
In prior office visit notes, it is documented by her physician that her back pain occurred across the L5-S1 level when she was in a sitting position and the claimant expressed her inability to work due to the sitting requirement of her job. Her physician expressed concerns regarding degenerative changes at the L5-S1 level because the CT scan performed on November 20, 2013 documented mild disc bulge at L4-5 and L5-S1 with mild narrowing of the central canal, early osteoarthritic changes in both SI joints, as well as indentation of the thecal sac at L5-S1 below the previous placed hardware. Additionally, in an office visit note from December 9, 2013, the physician stated that he believed the claimant could modify her work to get up once an hour to do stretching exercises. However, by March 27, 2014, it was clear that she experienced significant pain with activities, specifically bending, lifting and sitting, and he concluded that she was not capable of working for more than 4 hours with restrictions. On exam she was extremely uncomfortable and could not sit on the exam table, she could only lie flat. Exam revealed paresthesias in the buttocks and sciatic distribution with positive signs for sciatic tension, which followed the L4-5, L5-S1 distribution bilateral. In the standing position she was painful with flexion at 20 degrees or hyperextension. CIGNA completely disregarded the above opinions and medical records.
According to the Dictionary of Occupational Titles, the claimant’s occupation is classified as a “sedentary” occupation which requires lifting, carrying, pushing and pulling 10 lbs. occasionally, mostly sitting, and may involve standing or walking for brief periods of time. Based on the above, it was clear that the claimant was not capable of performing either her own occupation, or any gainful “sedentary” occupation.
After reviewing the appeal submitted by Attorney Alters, CIGNA overturned its decision to terminate benefits, paid her past benefits and put her back on claim. Attorney Alters will continue to manage her claim to help ensure CIGNA continues to pay her benefits.
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