Cigna Overturns Denial of Long Term Disability Benefits On Appeal
Author: Attorney Stephen Jessup
Prior to filing for long term disability benefits our client worked as a Sales Representative in the furniture industry. However, chronic back and neck pain resulting from unsuccessful back and neck surgery cut his career short. Once the physical demands became too much to handle he filed a claim for disability benefits with Cigna under this employer’s short and long term disability insurance policies. Our client initially experienced no difficulties in dealing with Cigna and his claim for short term disability was approved and then transitioned into long term disability without any issue from Cigna. Like the vast majority of Cigna disability insurance policies, our client’s policy contained a 24 month own occupation definition of disability, and like the majority of Cigna claimants his real difficulties began as he neared the end of the own occupation period, culminating in a denial of benefits three months prior to the change in definition to the “any occupation” standard of disability.
After receiving the denial letter our client contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup. Attorney Jessup’s review of the denial letter pointed to characteristics common to a denial of benefits from Cigna. In terminating the claim Cigna relied on very limited video surveillance and the opinions of an internal medical director and a nurse case manager, both of whom placed a large emphasis on video surveillance than medical evidence in rendering their opinions that our client would be able to return to “light” duty work. Despite the basis of the denial, of note to Attorney Jessup was the fact that our client’s policy contained favorable language as it related to what constituted “any occupation” under the policy. Specifically, the definition of any occupation contained an income component that the alternate occupation must be able to pay at least 80% of our client’s prior earnings- a fact that Attorney Jessup knew would work strongly in our client’s favor.
The policy language made it clear that the earnings requirement for “any occupation” greatly limited any vocational review that could be performed by Cigna. This resulted in his pre-disability occupation as a Sales Representative being determined as the only “any” occupation our client would be qualified to perform based on training, education and experience that would pay him 80% of his prior earnings. Effectively, our client’s policy was a de facto “own occupation” policy. This in turn begged the question – if Cigna had determined for over two years that our client could not perform the duties of his prior occupation, what had changed that led Cigna to believe he would not be able to? The answer was simple – the video surveillance.
Attorney Jessup’s review of the medical records clearly indicated that there was no substantive change in our client’s medical status that would indicate an improvement to a level that would allow him to return to his former occupation. To further verify and prove this fact on appeal, Attorney Jessup had our client undergo a Functional Capacity Examination, the results of which objectively indicated our client did not have the physical capacity to work at a Light duty demand occupation. As the medical evidence was clearly in support of our client’s claim, that left the video surveillance as the main basis of Cigna’s denial of benefits.
A good portion of the actual surveillance conducted by Cigna’s investigators culminated into the written report of the investigator, who had followed our client into the bar area of a popular chain restaurant where he overheard our client claim to “partake in fishing tournaments and be an avid outdoorsman” while he “consumed alcohol and conversed with patrons.” These claims were actually considered by Cigna’s medical staff as evidence of our client’s physical abilities. Ultimately, our client’s claim for disability was denied not because of a lack of objective medical evidence, but rather because of his tall tales of fishing over beers at a bar. This fact was the central theme of Attorney Jessup’s appeal and argument as to our client’s entitlement to continued benefits.
Cigna’s appeals department, presented with strong argument as to the arbitrary and capricious denial of our client’s claim, along with additional objective medical evidence in support of continued disability, was left with little choice but to reinstate our client’s claim for benefits.
This denial of benefits shows the lengths that Cigna will go to in denying a claim for benefits. Instead of relying on clinical medical evidence, the opinions of a treating physician, or even the opinions of an independent medical examiner, Cigna relied on inconsequential video surveillance that in no way established our client was able to return to work. Acting with relative impunity and a lack of any real concern as to being punished for such actions under ERISA, Cigna will look to deny a claim for any reason to see if a claimant will put up a fight. Thankfully, our client and Attorney Jessup, weren’t afraid of a good fight.
If you have a disability insurance claim with Cigna and have any questions regarding your claim, policy or concerns about Cigna’s actions please feel free to contact our office for a free consultation.