Cigna Overturns Denial of Long Term Disability Benefits
Author: Attorney Stephen Jessup
Our client, a former inventory control specialist for Johns Hopkins University, suffered a devastating stroke that ultimately left her wheelchair bound and with significant vision problems. Following the stroke she submitted a claim for disability insurance benefits through Johns Hopkins group employee disability plan with Cigna. Her initial experience with Cigna was not necessarily problematic as Cigna approved her short term disability claim followed by her long term disability claim without much issue. However, the long term disability plan language contained in the Johns Hopkins’ policy only had a 12 month “own occupation” period, which meant that Cigna would only review our client’s claim for disability eligibility as it related to her ability to perform her former occupation for 12 months and thereafter her ability to perform the duties of “any occupation based on her training, education and experience.” In light of this plan language, and despite having received an award of Social Security disability benefits, our client’s trouble with Cigna began soon after her award of LTD benefits.
The First Denial and Appeal.
Approximately seven (7) months into her claim for long term disability benefits Cigna advised our client that based upon a review of her file by medical personnel Cigna had determined that our client would not be disabled beyond the initial twelve (12) month period. At that time Cigna sent our client a check for the remaining five (5) months of “own occupation” benefits. To most people it would seem absurd that Cigna would be able to determine our client’s ability for work five months into the future while simultaneously ignoring the opinions of her treating physicians and the Social Security Administration as it relates to her entitlement to continued disability, but to Cigna it was just another claim denial.
In light of her medical condition and the information strongly in support of her continued right to benefits our client, with the assistance of her family, filed her appeal of Cigna’s denial of benefits. Although she provided additional medical evidence in support of her disability, after conducting yet another medical file review Cigna advised our client that it was upholding its denial of her claim for continued benefits.
The Second Appeal.
Following the denial of her appeal our client was referred by her Social Security disability attorney to Attorney Stephen Jessup to assist her in her fight against Cigna. Cigna is one of the few disability insurance carriers that provide a voluntary second level of appeal. Upon review of the information Attorney Jessup determined that it would be prudent to file the voluntary appeal on our clients behalf. However, the voluntary appeal comes with a very significant caveat- due to the fact that ERISA only requires one mandatory level of appeal that requires Cigna to have a file reviewed by personnel who had no hand in the claim denial, for purposes of a voluntary appeal Cigna is not required to have the second appeal reviewed by a fresh set of eyes who had no part in previous reviews. As such, Attorney Jessup knew that he would have to convince a Cigna doctor who had already determined that our client was fit for work that is opinion was wrong.
In all of the reviews conducted by Cigna, Attorney Jessup knew that the one piece of information that could be crucial in establishing that our client did not have the ability to work at a sedentary demand occupation as Cigna believed would be a functional capacity examination. Normally, when an FCE is performed a period of time after the denial of benefits an insurance carrier will typically argue that the results of the testing are not contemporaneous to the time of the denial and are therefore not an accurate reflection of physical ability. However, since Cigna denied our client well in advance of the change in definition of disability, and the fact that the denial of her first appeal came at the time of the end of the initial twelve (12) month benefit period, Attorney Jessup knew that the chances of Cigna outright ignoring the testing would be minimized.
Given our client’s physical state the FCE came back that she was unequivocally unable to perform any work on full time basis. Armed with the test results Attorney Jessup sent medical condition specific questionnaires to our client’s treating physicians that not only addressed the FCE findings, but also specifically targeted the medical reviews performed by Cigna. Attorney Jessup also made extensive argument against the vocational review performed by Cigna to systematically prove our client would not be able to perform the alternate occupations noted by Cigna’s vocational department.
After all the information necessary to file our client’s voluntary appeal had been compiled, Attorney Jessup submitted a thirty-four (34) page administrative appeal with one hundred and thirty (130) pages of additional medical information. Despite the overwhelming amount of evidence in support of disability, Cigna continued to find any way to deny the claim to include delaying the decision by taking their 45 day extension in order to perform additional medical reviews. Ultimately, Cigna was left with little choice and notified our office that it was reinstating our client’s claim for long term disability benefits.
Attorney Jessup continues to represent our client to ensure that Cigna does not try to terminate her claim again. If you have a disability insurance claim that has been denied or is under review and have questions regarding your claim, please feel free to contact our office to speak with one of our disability insurance attorneys.