Cigna reverses its decision to terminate benefits of a claimant with Fibromyalgia, Cervical Spine Spondylosis and Depression
Author: Attorney Rachel Alters
After paying the claimant for 24 months under the mental nervous condition limitation, Cigna terminated her benefits based on the lack of evidence supporting her physical disability. In its denial letter, Cigna dismissed the overwhelming volume of objective evidence supporting the claim for total physical disability (ie, significant abnormal findings on objective diagnostic testing, her credible complaints of pain, and clear observed limitations by her board certified physicians and specialists). However, it had always been the claimant’s contention that she was disabled and unable to work due to her multiple physical medical conditions which include Severe Fibromyalgia, Diffuse Myofascial Pain, Left Knee Pain, Cervicalgia, Insomnia, Cognitive Impairments, Cervical Spine Spondylosis, Bilateral Carpal Tunnel Syndrome, Bilateral Shoulder Pain, Bilateral Hand and Wrist Tenosynovitis, Headaches, Bilateral Neuropathic Upper Extremity Pain, Myofascial Pain Syndrome, Hypersensitivity Syndrome, Sacroiliac Inflammation and Anxiety and Depression secondary to her physical conditions. In an effort to avoid having to pay the claimant for greater than 24 months, Cigna conveniently labeled her claim “mental nervous” when the evidence in the records clearly demonstrated otherwise.
Cigna’s hired physician consultants to render opinions that the work restrictions imposed by her treating physicians were not supported by the documented measured limitations and there were no specific clinical limiting findings on physical examination. This of course was false.
After the claimant’s benefits were terminated, she retained Attorney Rachel Alters of Dell & Schaefer to help fight Cigna’s denial of her claim. Attorney Alters aggressively worked up her claim, recommended additional testing be done and obtained expert opinions from her treating physicians and filed an extensive appeal on her behalf.
Claimant was Involved in Car Accident During the Course of Her Claim Which Cigna Completely Ignored
The claimant was involved in a motor vehicle accident in August 2013 which exacerbated her fibromyalgia pain and caused unremitting stabbing pain in the lower back and hip which prevented her from sitting for prolonged periods and was relieved only with lying down. The medical records revealed at least 11/18 fibromyalgia tender points, decreased range of motion of the cervical and lumbar spines in all planes, increased pain with extension, and motor exam that was limited by pain in the upper and lower extremities with give way weakness. Cigna ignored all of this medical evidence and claimed that she was disabled only due to depression and anxiety for which benefit were only available for 24 months.
A Functional Capacity Evaluation Reveals that Claimant is Physically Disabled from Any Gainful Occupation
In order to refute Cigna’s claim that her claim was solely mental nervous, the claimant underwent a Functional Capacity Evaluation. According to the physical therapist, the claimant performed with maximal effort, her performance was consistent among FCE items, and her perceived abilities were consistent with her functional abilities objectively identified during the FCE. She reported a pain level of 7/10 at the start of the evaluation and 10+/10 upon completion of the FCE. It is noted that the testing had to be modified in order to allow her to be able to perform waist to floor lifts and kneeling. She moved in a slow manner with walking and transfers. She has slow gait with low heel contact and intermittent foot drag and catching of the left foot. She has a resting tremor present in the bilateral upper extremities. She had difficulties with tasks requiring her to lift/lower objects below waist level, is unable to fully squat or crouch due to weakness, and is limited to occasional walking due to slow gait with low heel contact and intermittent foot drag and catching of the left foot. She is limited with negotiating stairs due to lower extremity weakness and walking limitation. She is unable to carry items frequently due to her walking limitations. She has below average grip strengths of bilateral hands, poor hand coordination for bilateral hands. Her scores on pain screening questionnaire indicate a relatively high risk for developing long term problems. This was clearly not a woman that was solely suffering from depression and anxiety.
The FCE report was submitted to Cigna along with her appeal. Cigna eventually overturned its decision to terminate benefits, paid the claimant her past benefits owed and put her back on claim admitting that her disability was physical and therefore not limited to 24 months. Attorney Alters will continue to manage her claim to help ensure her benefits continue to be paid by Cigna.