Our client, an accounting manager for twenty-three years, suffered a debilitating stroke that left the entire left side of his body paralyzed. Coupled with the affects of the stroke, he also suffered from severe discongenic disease. Unable to work, he applied for and received Social Security Disability benefits from the Social Security Administration (“SSA”) after meeting the SSA’s very strict definition of “disabled”. Shortly thereafter he applied for long-term disability benefits with his insurance carrier, CIGNA, under the terms of his employer’s disability policy and was subsequently awarded his disability benefits.
Two years after his award of long-term disability benefits, CIGNA informed him that his twenty-four month disability period for his “own occupation” was drawing near and further investigation would be conducted to determine his claim for further long-term disability benefits. Our client complied with all the requirements and requests from CIGNA in order to maintain his disability benefits, but to no avail, CIGNA denied further long-term disability benefits.
In their denial of benefits, CIGNA indicated to our client that he still had the use of his right upper and lower extremities and was thus able to perform the duties of his occupation. In response to the denial letter, we prepared an administrative appeal. In the appeal, we noted that CIGNA based its denial on a telephone conference, an alleged review with an in-house vocational expert, and a review with an in-house Nurse Case Manager; all of which were never disclosed to the insured or his counsel. Furthermore, we noted that CIGNA never spoke to our client before denying him his rightful benefits, nor did they consult with any medical specialist in the fields of medicine applicable to his conditions.
With the overweighing evidence in the appeal provided by us, and medical specialists, treating physicians, and vocational rehabilitation experts, CIGNA agreed to reinstate his long-term disability benefits and pay back benefits covering the period of time in which he was wrongfully denied.