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Cigna reverses decision to terminate benefits of claimant suffering from end-stage Myasthenia Gravis

Attorney Rachel AltersAuthor: Attorney Rachel Alters

After receiving a letter terminating her LTD benefits, the claimant retained Rachel Alters to prepare an appeal on her behalf against Cigna. The medical and occupational documentation submitted with the appeal clearly established that due to physical limitation resulting from end stage Myasthenia Gravis, which causes the claimant to suffer unpredictable, intermittent muscle weakness in her arms, shoulders, back and legs which is activity-induced, bulbar symptoms (facial weakness, difficulty chewing, swallowing, articulating, breathing, and weakness of the neck muscles), vision field loss, double vision, drooping eyelids and slurred speech, rendering her unable to perform with reasonable continuity the material duties of any occupation for which she is, or may reasonably become, qualified based on education, training or experience.

Cigna cherry picks medical records in order to attempt to justify termination of benefits.

In its denial letter, Cigna dismissed the overwhelming volume of objective evidence supporting her claim for total disability (i.e., significant abnormal findings on objective diagnostic testing, her credible complaints of pain, weakness and fatigue, and clear observed limitations by her board certified physicians and specialists). Cigna cherry-picked information from each of these documents which was able to be construed to purportedly support Cigna’s contention that the claimant no longer met the LTD Plan’s definition of disability and was no longer eligible for continued benefits. Moreover, Cigna overlooked the fact that the condition she suffered from is a chronic condition from which the claimant has not gone into remission. After paying her benefits for nearly 4 years, Cigna was clearly looking for a way to stop paying the long term disability benefits to which she is entitled.

In support of her claim, her neurologist submitted an Attending Physician Statement stating the claimant had no functional capacity and that she was unable to perform work of any kind. Her psychiatrist submitted an Attending Physician Statement dated which indicated that her DSM IV Diagnosis was: Axis I: major depression in remission; Axis II: none; Axis III: Myasthenia Gravis; Axis IV: moderate stress; Axis V: GAF 55. It was noted she had depressed mood on an off and difficulty dealing with high stress situations. Additionally, she exhibited trouble focusing on sustained mental activities, and had very limited capacity to maintain 8 hours of job. He indicated that she was not able to return to work and had limited capacity to maintain her home life and was not able to maintain work life.

Cigna sends clamant for an FCE in attempt to validate termination of benefits.

In January 2012, LTD benefits were continued based on an Attending Physician Statement submitted by her physician supporting continued disability due to Myasthenia Gravis. Cigna no longer wanted to pay her claim since it was already determined that she was never going to get better, could never work, and would not accept a buyout, Cigna had to find another way to get rid of her claim so they would not be responsible for paying close to $600,000 in benefits over the next 13 years. In doing so, they sent her for an FCE that was clearly biased, inaccurate and inconsistent in order to obtain and opinion that she could return to work.

Cigna ignored all of the FCE findings and observations that supported the claim that she cannot sustain the functional capacity to work full time due to the effects of her Myasthenia Gravis. Instead, they used the fact that she lifted a certain amount of weight for an allotted period of time, under ideal clinical conditions, to justify that she no longer met the LTD Plan’s definition of disability and was no longer eligible for continued long term disability benefits. Despite the clear discrepancy between the Functional Capacity Evaluation that Cigna conducted and the opinions of the claimant’s neurologist and psychiatrist, who both treated her for many, many years, Cigna took no further action to clarify or resolve the discrepancy.

As a result of her Myasthenia Gravis, she suffers from unpredictable, intermittent flares of generalized muscle weakness which is induced by sustained physical activity. She not only suffers muscle weakness in her arms, shoulders, back and legs, but the disease also causes weakness of facial muscles causing eyelid drooping, as well as difficulty swallowing, speaking (her speech begins to slur to the point of being intelligible), and it also leads to difficulty breathing, which has the potential to be life threatening. Her illness is chronic and progressive. She will never get better and never be able to return to work.

After reviewing the appeal submitted by Attorney Alters, Cigna realized its decision to terminate benefits was wrong. Cigna reversed its decision, paid the claimant her back benefits and put her back on claim. Attorney Alters will continue to manage her claim to help ensure she remains on claim as long as she remains disabled.

Read more about Cigna disability claims, user reviews and complaints here.



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