Our client was the epitome of a no-nonsense, honest, hardworking individual. So much so that at the age of 64, while performing yard work at his home he fell some 30 feet from a tree, breaking multiple vertebrae in his back and still attempted to return to his occupation as a Software Engineer. Despite his noble efforts, the severity of the fall that almost killed him and required extensive surgery left him unable to perform the duties required of his occupation.
Unable to return to work he filed a claim for disability benefits with Cigna and with the Social Security Administration. It would seem that given the nature of the injury and our client’s age that there would be little problem with his benefits being approved. Following that logic, Cigna initially approved his claim for disability benefits with Social Security soon following.
The Denial of Long Term Disability Benefits.
Like many long term disability policies governed by ERISA, the maximum benefit under our client’s policy was 65. However, common to many policies, if disability occurs after the age of 61, benefits will be payable for a designated number of months. In our client’s case his long term disability benefit was to be paid for 36 monthly payments.
Less than 18 months after his accident, and only 14 months after his claim for long term disability benefits was approved, at the age of 65, Cigna determined that our client could return to his former occupation. It was then he contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup. Based on all the surrounding facts and circumstances of the case even Attorney Jessup was surprised that Cigna would deny the claim.
Attorney Jessup set out immediately to obtain a copy of Cigna’s claim file as well as a copy of all of our client’s medical records. In reviewing the medical review performed by Cigna’s doctor, who never physically examined our client, Attorney Jessup was astounded to find that the doctor opined that there was “no quantifiable clinical exam, clinical testing or imaging documentations to support a significant ongoing physical impairment” that would preclude work. This opinion was made despite having the medical documentation containing three MRIs, seven X-rays, EMG and Nerve Conduction Studies, two CT Scan, two Myelograms and numerous medical records from our client’s doctors which documented his physical restrictions and limitations.
In preparing the appeal, Attorney Jessup systematically undermined the opinion of Cigna’s doctor by highlighting all of the inconsistencies and contradictions contained in the report. Efforts were then coordinated with our client’s doctors to provide additional medical support and proof of continued entitlement to disability benefits. When all the supporting information was secured, Attorney Jessup finalized and filed the lengthy and detailed appeal. Presented with clear evidence of its improper denial of benefits, Cigna was left with little choice and overturned its erroneous denial.
Long term disability benefits are never guaranteed.
Our client is a classic example of this reality. At the age 65 after having suffered a broken back in an accident that could have killed him, who had only approximately two years of benefits left under the policy, our client would not have seemed to be a likely candidate for a claim denial. However, the reality of long term disability insurance is that an insurance carrier will always look to find a way to deny a claim for benefits no matter the age or disability of the individual.
If your claim has been denied or you are concerned that your insurance company may be looking to deny your claim, please feel free to contact our office for a free consultation.