In early 2019, the widow of a decease man contacted our firm as she was troubled by the actions of CIGNA, also known as Life Insurance Company of North America. Prior to contacting our firm, the lady’s husband had died from metastatic prostate cancer in July of 2018. Through his prior employer, the decedent was covered under two insurance policies: (1) a group long term disability insurance policy that provided monthly income replacement benefits should he be found to be disabled, and (2) a group life insurance policy.
After initially being diagnosed with prostate cancer in December 2010, the man courageously worked until January 2015 when his body essentially said no more as the cancer had metastasized to his bones and other parts of his body. After ceasing work and while fighting his disease in treatment centers throughout the country, the man filed for Long Term Disability benefits under the Long Term Disability Insurance Policy provided through his employer.
After reviewing his claim, Cigna found the man to be disabled under the terms of the Long Term Disability insurance policy and began paying LTD benefits as of July 2015. After approving his claim for LTD benefits, Cigna then began a review for an approval of “Waiver of Premium” benefits claim under the Group Life Insurance Policy.
Under the terms of most Group Life Insurance Policies, typically your coverage will cease when your employment ceases. However, most Group Life Insurance Policies have a provision that your coverage can continue without the need of paying any premiums should one be found to be disabled under the terms of the Group Life Insurance Policy. Unfortunately for the decent in this claim, despite CIGNA finding him to be disabled under the terms of the LTD plan (which required him to be “unable to perform the material duties of his regular occupation” for the initial 24 months and then any occupation thereafter) due to his metastasized cancer, CIGNA found him to not be disabled under the terms of the Group Life Insurance Policy.
To be disabled under the terms of the Group Life Insurance Policy, one must prove that one is “unable to perform all the material duties of any occupation which he or she may reasonably become qualified based on education, training or experience.”
By way of a January 6, 2016 denial letter, CIGNA stating that it was denying his claim for Waiver of Premium benefits based on reviews by its Nurse Case Manager and Medical Director. It noted that medical records reported that “you were swimming five times per week” and there “were no noted abnormalities in your physical examination.” Ultimately, CIGNA believed that despite paying his LTD claim that the former Chief Commercial Officer making a yearly salary of $292,500 could do a sedentary occupation including the role of a customer-compliant clerk (whatever that is).
Thinking this is a clear mistake, the claimant and his wife filed a quick appeal to CIGNA asking it to overturn this denial. Unfortunately, CIGNA upheld its decision to deny the Waiver of Premium claim via a June 23, 2016 appeal denial letter. For justification of denying the appeal, CIGNA now cited to three separate peer reviews by outside doctors including Oncologist Dr. Mark Levin, Rheumatologist Dr. Sofia Aksentijevich and Occupational Medicine Physician Dr. William Jennings. Using these “independent” consultants, CIGNA agreed that the claimant had support for some functional limitations due to his conditions, but not enough to be precluded from all work. Cigna thus upheld its denial.
The June 23, 2016 allowed the claimant to file an additional appeal to challenge this denial but unfortunately an additional appeal was never timely filed and a lawsuit was never brought. The reason a 2nd appeal or a lawsuit was never filed was due to the fact that following this appeal denial, the claimant and his wife essentially traveled the country in a desperate attempt to treat him for his metastasized cancer. Frankly, the now deceased man had other things to do then to fight with CIGNA over a wrongful denial as he was doing everything and going anywhere to stay alive.
Sadly, the claimant died on July 17, 2018.
In early 2019, the widow found our firm, reached out to us and spoke with Attorney Alexander Palamara. Despite a timely appeal not being filed and despite the time limit to file a lawsuit having already run, Attorney Palamara took on the case as he believed he would be able to show that CIGNA must overturn this denial and pay the widow the Life Insurance Benefits she was owed.
On the same day this firm was hired, we reached out to CIGNA to let them know that the denial was unjust and that a full challenge to this denial would be forthcoming. A formal appeal was filed shortly thereafter with additional medical documentation and argument as to why this denial was wrong and illegal. The Appeal pointed to the medical documentation, treatment history, and Long Term Disability Approval by CIGNA and the fact that CIGNA had found him disabled from Any Occupation standard under the LTD claim. The appeal also noted that the decedent had been found to be disabled by the Social Security Administration and challenged the occupations CIGNA found as appropriate for the former Chief Commercial Officer. Lastly, the appeal highly criticized the biased opinions given by CIGNA’s Nurse Case Manager and Medical Director, as well as those of the “independent” consultants. All in all, the appeal proved that whoever decided to deny the Waiver of Premium claim initially and on appeal made a terrible and unjust decision that was egregious, immoral as well as arbitrary and capricious.
Despite a strong appeal, a major issue with this claim still existed in the fact that a timely 2nd appeal nor a lawsuit was ever timely filed. Despite the evidence and argument put forth by Attorney Palamara, CIGNA could have denied the claim as being untimely.
Thankfully, our appeal was successful and by way of a February 1, 2020 letter wherein CIGNA informed our firm and the widow that a decision had been made to overturn its prior denials. Since receiving that letter, we have now received the Life Insurance Benefits which are in the hundreds of thousands of dollars and the widow has received the money she has been owed since the time of her husband’s death.
In the end, we must commend the actions of CIGNA for ultimately doing the right thing with this claim. Although they initially denied the claim, almost never paid benefits, and made it very tough on this widow, they ultimately did pay even though it was questionable whether they had to do so as the time limits to file suit had run. However, it is apparent that CIGNA realized the previous errors of its ways and corrected an injustice that it had previously caused.
The widow has now been paid the monies that she has been owed for some time and is thankful for the work of Attorney Alexander Palamara, the firm of Dell & Schaefer and even the people at Cigna who ultimately agreed to right this wrong.
If you have had a love one die and CIGNA or any insurance company has failed to pay life insurance benefits due to an improper denial of a Waiver of Premium Claim (or for whatever reason), please do not hesitate to reach out to our firm. We always offer a same day free consultation with an attorney and would love the chance to speak with you and right any wrong caused by the insurance company.