Prior to filing for long term disability benefits, our client had worked as a night tool pusher on an offshore oil rig. His job required long, stressful hours in a very dangerous and difficult environment. Following an incident at work our client began experiencing troubling dreams, depression, anxiety and panic attacks that were so severe he had to be hospitalized. Following his hospitalization he made a claim for long term disability benefits with Cigna under his employer’s group disability insurance policy.
The First Denial Of Long Term Disability Benefits By Cigna
In reviewing our client’s application for disability benefits, Cigna had his claim reviewed by a behavioral health specialist and one of its internal medical directors. Despite noting the severity of his condition and the need for hospitalization due to suicidal and homicidal ideations occurring throughout the 180 day elimination period, Cigna focused on a single medical record from his doctor, which noted that he was no longer experiencing suicidal or homicidal ideations. Based on this one statement in one medical record, Cigna decided to ignore everything that came before and after it and denied his claim for benefits. The worst part is the fact that this medical record was written two days before the end of our client’s elimination period was to end and benefits were to be paid! Cigna’s position was that our client only satisfied 178 days of the 180 day elimination period, and was therefore not disabled or entitled to benefits.
The First ERISA Appeal Submitted to Cigna
Following receipt of the Cigna denial letter, our client contacted Attorneys Dell and Schaefer and consulted with Attorney Stephen Jessup. Attorney Jessup obtained and reviewed Cigna’s claim file and noted that crucial medical records relating to our client’s hospitalization, as well as records from some of his treatment providers were not present. Particular focus and attention was paid to the medical records that corresponded to the period of time in which Cigna had determined our client was not “disabled,” as Attorney Jessup knew that Cigna would potentially argue that our client would be deemed disabled as of the time of the filing of the appeal, but that he was not at the time of denial and therefore he still failed to satisfy the elimination period. Attorney Jessup coordinated with our client’s doctors to clarify records and expand upon their opinions as to the disabling nature of our client’s condition. Armed with additional medical records and updated opinions and letters from his treatment providers, the appeal was filed.
The Second CIGNA Disability Denial Required Another ERISA Appeal
The appeal was filed. However, Cigna was not ready to give up without an additional fight. In denying the appeal Cigna had turned its attention away from the argument that our client had not satisfied the elimination period in the policy to an all too common argument that there was no clinical evidence to support our client’s inability to perform the duties of his occupation. Despite the incredibly detailed medical records and reports submitted with the first appeal, Cigna was not moved. Following the denial, our client was faced with the option of bringing a lawsuit against Cigna or undertaking a voluntary appeal offered. Attorney Jessup consulted with and advised our client that the filing of a voluntary appeal could save him from protracted litigation and afford one last opportunity to make his claim as strong as possible if a lawsuit had to be filed.
The Second Appeal
Not backing down, Attorney Jessup acquired the updated claim information created by Cigna in support of its second denial of our client’s claim. Review of same revealed Cigna’s tactic for denial and allowed Attorney Jessup to prepare the proper counter arguments not only to the reason for the most recent denial, but also the arguments he expected would flow from same. Attorney Jessup coordinated for additional testing that would help support the restrictions and limitations expressed by our client’s doctors and reached out to them for further comment on Cigna’s denial. When the additional testing and information was complete, the second appeal was submitted.
The Final Decision by Cigna
Even faced with additional medical documentation supportive of our client’s claim for benefits under the Policy, Cigna continued to be contentious during the appeal review process. Cigna employed customary tactics of requesting treatment providers to respond to reports and letters within a short timeframe with failure to do so resulting in a final review based on the reports generated by Cigna’s medical reviewers. Attorney Jessup was aware that Cigna would attempt same and took preemptive steps in the appeal to ensure Dell and Schaefer would not be bypassed in the process. As a result, Attorney Jessup followed up with all of our client’s doctors to ensure responses and/or information requested was provided within the time frame established by Cigna.
Following a request for a 45 day extension to render its decision on our clients final appeal, Cigna was eventually left with no choice but to overturn its denial of our client’s claim for benefits and forward all benefits owed. Of note is the fact that our client’s policy contained a 12 month limitation on benefits for disability caused by Mental Health disorders. Our client’s fight with Cigna took over a year before he was awarded what was rightfully his.
Are You On Claim For A Mental Health Disorder?
In our experience speaking with hundreds of insureds, many believe that when their disabling condition is subject to a limited pay period the insurance company will not fight the claim as hard because they are only “on the hook” for a limited period of time. This case serves as a potent reminder that even when an insurance policy has imposed benefit limitations in a policy for conditions such as Mental Health disorders, they will still review and fight the claim as hard as they would any other claim not subject to a limited benefit pay period limitation. If you are on claim for a Mental Health disorder or are thinking of filing a claim, please contact Attorneys Dell & Schaefer for a free consultation.