Our client, Mr. W, formerly worked as a freight truck driver for a shipping company. In January 2015 a number of medical issues, including Diabetes as well as lung and kidney problems, forced Mr. W to stop working and submit his claim for disability benefits, first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by CIGNA.
Although Mr. W’s occupation as a truck driver was quite physically demanding, he would be considered totally disabled under his employer’s disability policy if he was unable to perform the material and substantial duties of “any occupation” for which he was reasonably qualified, which is a much more lenient standard for the insurance carrier to meet.
After paying Mr. W for the maximum benefit period under the STD policy, CIGNA approved his LTD benefits for just 2 months then denied his claim on the basis that he allegedly no longer met the policy definition of disability. Specifically, CIGNA determined that “it did not appear that his symptoms were at a level of severity that would necessitate an ongoing preclusion from work.” Mr. W appealed the decision and his claim was again denied. On appeal CIGNA determined that his supported restrictions and limitations would not preclude him from performing sedentary occupations. CIGNA also conducted a vocational review and identified three gainful occupations Mr. W could allegedly perform. Following the denial, Mr. W was offered a voluntary second level of appeal.
After receiving the second denial, Mr. W contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in CIGNA’s previous denial letters and in the physician consultant’s medical reviews, and agreed to prepare and submit Mr. W’s voluntary ERISA appeal with the assistance of his appeal team.
The appeal addressed all of CIGNA’s short-comings and reasons for denial, with a special focus on the review conducted by CIGNA’s in-house nurse consultant and medical peer review physicians. One of the focal issues was the potentially prejudicial information CIGNA’s claims personnel shared with the medical reviewers and the reviewers offering claims opinions outside the scope of their expertise.
Approximately ninety days later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, CIGNA overturned its decision to terminate the claim and reinstated Mr. W’s long-term disability benefits.
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