An Industrial Maintenance Supervisor was forced to stop working after degeneration of the spine and several failed lumbar spine surgeries left him unable to work. His conditions were so bad that he required the use of a wheeled walker and he was left unable to sit or stand for more than a few minutes at a time. As a result of his inability to work, the former Maintenance Supervisor applied for LTD benefits with Cigna and was initially paid benefits for the first 24 months of his disability under the “own occupation” period of the policy. Unfortunately, benefits beyond the initial 24 months were denied.
In this policy that he had coverage under through his employer, what it means to be disabled changed after the initial 24 months of benefits were paid. This is common in most group long term disability insurance policies. Typically, for the first 24 months, claimants need only prove that they cannot perform the duties of their own occupation. At the 24th month mark, it gets more difficult to qualify for benefits as one must then prove that they are unable to perform the duties of any occupation for which they are qualified based on their training, education and experience. This 24 month mark is the most common point when approved claims get denied.
Claim Denial Due to Change in Definition of Disability
For the Industrial Maintenance Supervisor, Cigna initiated a review of his claim a few months prior to the “change in definition of disability” and ultimately determined that he was now capable of performing a sedentary occupation. As such, Cigna decided that he no longer met the definition of disability under the policy and denied further benefits.
In support of its decision to deny the claim, Cigna relied upon reviews by its in-house Claims Manager, Senior Claims Manager, Nurse Case Manager, and Medical Director. Each of these people were employed by Cigna. Despite the former Maintenance Supervisor’s inability to sit or stand for more than a few minutes, Cigna’s Medical Director found he was capable of frequently sitting with accommodations to change position every 30 minutes. Cigna’s Medical Director also found that the claimant possessed the physical capabilities necessary for sedentary work. Cigna also had its in-house vocational department perform a vocational analysis which identified two sedentary occupations the former Maintenance Supervisor was allegedly qualified for. Thus, Cigna concluded he no longer met the definition of disability as it believed he could do sedentary job and his claim was denied after the expiration of the first 24 months of disability payments.
Unfortunately, the former Maintenance Supervisor was barely capable of walking and unable to return to any type of full time employment, which was fully supported by all of his treating physicians. Thus, he knew Cigna’s conclusion was wrong. Upset his claim was denied and in disagreement with Cigna’s reasoning for denying his claim, he decided to find assistance with his claim and found Attorney Alexander Palamara of the Dell & Schaefer law firm.
Appeal by Attorney Palamara
After reviewing the denial letter by Cigna and speaking with the former Maintenance Supervisor, it was clear to Attorney Palamara that Cigna’s denial was improper and his client was unable to work due to serious and debilitating conditions. The claim file from Cigna was ordered along with our now clients past and current medical records to develop a full understanding of his conditions, his claim, the governing policy, and Cigna’s handling of this claim. After compiling and reviewing all the necessary information, it was clearer than ever that his benefits had to be reapproved. A detailed review of the claim file revealed inconsistencies in the opinion of the Medical Director who provided no support of his findings that the former Maintenance Supervisor was capable of sedentary work.
An appeal was drafted and timely filed. The appeal focused on the objective medical evidence in support of his claim, including among others, a history of 7 prior lumbar surgeries; decreased range of motion; multiple positive MRIs of the lumbar spine; positive lumbar spine CT Scan; and an abnormal gait with need for a prescribed a power operated vehicle due to an inability to ambulate more than 8 feet with the use of an assistive device. The former Maintenance Supervisor also underwent a Functional Capacity Evaluation which confirmed what his doctors’ opinions that he was not able to sit and perform sedentary work for an 8 hour work day.
The appeal also highlighted the inconsistencies in the opinion of Cigna’s Medical Director and Cigna’s questionable reliance on this opinion despite multiple supportive opinions by the former Maintenance Supervisor’s treating physicians.
Thankfully, two months after the appeal was filed, our client’s claim was reapproved 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 is unable to work at any occupation.
Our client is relieved to be back on claim and was happy to receive the benefits that he was owed since the time they initially denied the claim. Based on Cigna’s past conduct, it may make another attempt to deny benefits in the future, but Attorney Alexander Palamara will do whatever it takes to keep the former Maintenance Supervisor 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.