Prior to filing for disability our client worked as a Tugboat Captain on the Mississippi River, responsible for tugging large vessels in narrow waters to ensure the safety of the vessel, and also to prevent potential accidents and environmental disasters. However, due to loss of vision in his left eye, migraines and chronic back pain requiring use of narcotic medication that affected his ability to concentrate, he was forced to step down from his duties and apply for long term disability benefits under his employer policy with Life Insurance Company (Cigna).
The First Denial and Appeal
Despite what would seem to be strong medical evidence that would prevent our client from performing his duties as a Tugboat Captain, Cigna initially denied his claim for benefits based in part upon six separate days of video surveillance and a medical file review of his records by one of its internal doctors. Not understanding the importance of filing a complete and detailed appeal that provides strong medical support and evidence of disability, our client filed his first appeal with the assistance of a firm that did not handle ERISA based disability claims.
The appeal submitted to Cigna argued, rightfully so, that our client was disabled from performing his duties as a Tugboat Captain as his license to operate a thousand-ton vessel had been taken away by the United States Coast Guard. However, his disability policy, like almost ever policy, clearly indicated that the loss of a License alone was not enough to establish a total disability for purposes of securing benefits. During the appeal process Cigna sent our client for an Independent Medical Evaluation with an eye doctor, whose examination indicated that our client was not being truthful with his reported vision problems and symptoms. Based on the video surveillance, the IME report and what it deemed to be a lack of any new information to medically support restrictions and limitations Cigna upheld its initial denial of benefits.
The Voluntary Appeal
Following receipt of the denial of his first appeal our client contacted our office and spoke to Attorney Stephen Jessup to discuss his options against Cigna. Attorney Jessup advised him that following the denial of his mandatory appeal he would have the right to file a lawsuit under ERISA. However, given the information contained in the file Attorney Jessup recommended that our client exercise his right to the voluntary second appeal offered by Cigna under his policy. The voluntary appeal focused on undermining the nature video surveillance, which largely documented periods of inactivity or limited activities of daily living; as well as Cigna’s failure to consider all of our client’s medical conditions when evaluating his claim for disability.
The appeal submitted by Attorney Jessup argued that our client’s ability to grocery shop or run errands was in no way indicative of his ability to perform the duties of his occupation and to try to argue otherwise was evidence of an arbitrary and capricious review of the claim. In addressing the medical records, Attorney Jessup noted that Cigna’s review as focused almost exclusively on our client’s vision problems and failed to take into consideration his extensive back and neck issues and the effects of his medication on his ability to perform his occupational duties. Confronted with argument and evidence that clearly established disability Cigna overturned our client’s denial of benefits, forward all back benefits owed and put our client on claim.