Cigna reinstates LTD claim after reviewing Dell & Schaefer appeal

Mr. M contacted our firm after receiving a letter from his disability insurer that he no longer qualified for disability benefits under his employer sponsored LTD plan. Cigna, also known as Life Insurance Company of North America (LINA), had paid disability benefits to Mr. M for two years due to his inability to work as a Process Operator for Formosa Plastics Corporation, USA. Mr. M suffers from a host of medical conditions including Chronic Pain Syndrome, various spine issues at all three levels, migraines, hypertension, as well as sleep disorders and gastro intestinal issues. During the first two years on claim Mr. M’s LTD policy required him to be unable to perform the material duties of his regular occupation as a Process Operator. However, like many group disability policies, the definition of disability changed in his policy after 24 months of benefits.

CIGNA’s Initial Decision to Deny LTD Benefits and the Decision to Contact Dell & Schaefer

After paying Mr. M benefits for 24 months, Cigna found that Mr. M was capable of performing an occupation at the sedentary exertion level. Cigna’s decision was based on a Peer review and Independent Medical Examination (IME). Based on these findings, Cigna found that Mr. M should be capable of performing certain sedentary occupations including that of a Maintenance Service Dispatcher or a Work Order Sorting Clerk. When Mr. M contacted our firm, he was also receiving social security disability benefits for the same disabling conditions. After speaking with us, we decided to take on the case and help Mr. M appeal Cigna’s decision to terminate Mr. M’s claim.

Appeal of CIGNA’s Denial

After receiving a copy of the claim file from Cigna, our team reviewed the IME report and Peer Review Report on which Cigna relied and a plan of action was set in motion. It soon became apparent that Cigna’s Peer Review was insufficient to support the conclusions reached in the Peer Review Report.

The Peer Review had been performed by Cigna’s hired medical consultant, Dr. Jaime Lewis. Upon reviewing Mr. M’s medical records, Dr. Lewis acknowledged that the records indicated physical dysfunction but concluded that Mr. M could lift, carry, push and pull 20 pounds occasionally. He could allegedly sit 60 minutes continually up to 8 hours per day with the ability to alter standing and walking as needed. He could allegedly stand and walk 10-15 minutes at a time up to 3 hours a day. He could allegedly reach overhead and below waist occasionally. He could allegedly reach at desk level, handle, finger, feel, and simple grasp unrestricted.”

Based on the above restrictions, Cigna determined that Mr. M was capable of performing at the Sedentary level of functioning. Interestingly, Dr. Lewis specifically stated that it is unlikely that that Mr. M would have the ability to return to full-time employment without restrictions given his history of cervical fusion.

In support of Mr. M’s appeal, Dell & Schaefer obtained custom questionnaires from Mr. M’s treating physicians specifically addressing the gaps in Mr. M’s medical records as well as the issues in Cigna’s review. Ms. M’s treating physicians provided detailed explanations corroborating Mr. M’s disability.

Cigna and its Peer Reviewer had overlooked or ignored the fact that the most recent medical records showed that Mr. M’s disability had progressed for the worse in his upper extremities and that his condition would preclude him from working any type of sedentary job. The evidence clearly indicated that Mr. M’s functioning in his cervical spine has continually deteriorated.

In addition to the Peer Review Report, Cigna relied on an old IME report it had performed months before the 24-month mark which concluded that Mr. M could perform sedentary work. However, the IME report documented a less than thorough evaluation.

Dell & Schaefer argued that if Cigna had been interested in obtaining the most accurate assessment of Mr. M’s true functional limitations then a Functional Capacity Evaluation (“FCE”) would have been requested. But Rather than requesting a functional capacity evaluation, Cigna chose to rely on a peer review and independent medical evaluation to determine Mr. M’s functional limitations.

Since Cigna did not request one and to provide more objective evidence of Mr. M’s functional limitations, Dell & Schaefer had Mr. M undergo an independent FCE to provide additional support for Mr. M’s claim. The results of the FCE confirmed that Mr. M has a less than sedentary level of work ability. The FCE report along with custom questionnaires from treating physicians and a thorough outline of the objective or clinical evidence corroborating Mr. M’s disability claim were submitted to Cigna in support of the appeal.

CIGNA Reinstates the LTD Claim

After reviewing the appeal submitted on Mr. M’s behalf Cigna had no choice but to reinstate Mr. M’s LTD claim. Our office was notified by phone that Mr. M’s LTD claim had been reopened and all back benefits due to Mr. M would be paid.

Dell & Schaefer continues to manage Mr. M’s claim with Cigna to ensure Mr. M has the best chances of staying on claim for as long as he remains disabled under the terms of his disability plan.

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Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Reviews

Bruce R. (Arizona)

Steve Dell has done an exceptional job with my disability application process. The firm is extremely well managed. They have acquired an incredible amount of experience over many years. I recommend them for disability insurance claims without reservation. 

Don (Florida)

I called this firm a few months ago completely disparaged due to a company cutting off disability benefits at a time that nearly caused me to lose everything.

Attorney Alex Palmera and Danielle worked hard to reach an amicable settlement and my case was settled a few months later. This is a good firm and the specific expertise in disability claims saved me countless hours of hassle at a time when an already fragile state existed.

Thank you Mr. Palamara and Danielle.

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