Our client was previously employed as a Computer Systems Engineer. In this occupation, he was responsible for support and maintenance of a real-time system that allows pipeline controllers to monitor pipelines across the United States. Unfortunately for him, he was suffering from Lumbar Discogenic and Facetogenic Pain, Lumbar Radiculopathy, Cervical Spine Pain Status Post Fusion, and Piriformis Syndrome, and required narcotic pain medication. Due to his various conditions, he was unable to continue to work and he therefore filed a claim for LTD benefits under a policy he was covered under by way of his employment. Unfortunately, his claim was denied by Cigna who found that he simply did not meet the definition of disability.
In addition to his physical conditions, the claimant was also suffering from severe cognitive deficits as a result of the narcotic pain medication he needed to control his constant and severe pain. Additionally, he was scheduled for an additional back surgery, and as a result, he was unable to return to any type of full time employment. Although his claim was denied, he knew he couldn’t work and he knew Cigna’s conclusion was wrong. As such, he decided challenge this denial by filing an appeal on his own appeal. The claimant provided Cigna with additional medical records and argued his denial should be overturned because the narcotic pain medication caused cognitive deficits. Unfortunately, his appeal was denied.
In denying the appeal, Cigna once again denied LTD benefits despite a finding by Cigna that he was eligible for Waiver of Premium benefits on a life insurance policy based on the same disability. Neither Cigna nor its claim file reviewers provided a reasonable rationale for its contradictory conclusions regarding the claimant’s disability. Cigna also failed to perform a Functional Capacity Examination (FCE) or Independent Medical Examination (IME) to obtain a true assessment of the claimant’s residual functional capacity, even though the policy governing his claim allowed Cigna to have such an examination conducted.
Upset his appeal was denied and still unable to work, the claimant decided he needed assistance with his claim and found Attorney Alexander Palamara of the Dell & Schaefer law firm.
Appeal by Attorney Palamara:
After reviewing the denial letters, speaking with the claimant, and reviewing the claimant’s appeal, it was clear to Attorney Palamara that Cigna’s denial was improper and that his now client was unable to work. The claim file from Cigna was ordered along with our now clients past and current medical records. Those documents were reviewed to develop a full understanding of his illness, claim, policy, and Cigna’s handling of his claim. After compiling and reviewing all the necessary information, it was clearer than ever that his benefits should be approved.
A detailed review of the claim file revealed Cigna found the claimant disabled under its waiver of premium provision for the Life Insurance Policy, but there was no rationale for its contradictory conclusions regarding his disability under the LTD policy. The review also revealed that Cigna failed to perform a thorough review of Mr. Dehart’s medical records and failed to have a medical doctor of the appropriate specialty perform an examination. Instead, Cigna relied on an inadequate and incomplete paper review and a flawed vocational analysis.
An appeal was drafted and timely filed. The appeal focused on the objective medical evidence in support of his claim, highlighting individual records that contradicted specific allegations by Cigna in its denial. Also included were physician statements that the claimant was limited from prolonged sitting, standing, walking and records showing that his necessary medications affected his cognition, memory and decision making skills. The appeal also highlighted the inconsistencies in the opinion of Cigna finding the claimant disabled and eligible for waiver of premium benefits, but not disabled for LTD benefits, and the failure of Cigna to perform an IME in light of conflicting findings between the claimant’s treatment providers.
After filing the appeal and providing Cigna with ongoing, updated medical records, Cigna noticed the claimant for an Independent Medical Examination (“IME”). The IME was coordinated through Attorney Palamara and took place roughly 4 months after Attorney Palamara filed the second appeal on the claimant’s behalf. One month after the IME was completed, Cigna overturned its denial. Our client’s claim was approved and all back benefits that were owed were paid in full. With the assistance and support of his treating providers and their medical records, Attorney Alexander Palamara was able to successfully argue to Cigna that our client was disabled under the terms of the policy.
Our client is relieved to be on claim and to have received all the money that he was owed. Cigna attempted to deny our client’s claim without conducting an IME and properly investigating his claim, but Attorney Alexander Palamara was successful by providing updated medical records and highlighting the legal deficiencies in Cigna’s denial. Attorney Palamara will continue to do whatever it takes to keep the former Computer Systems Engineer on claim until he is able to return to work or until his policy expires.
If you have been denied disability benefits by Cigna or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.