Court rules Cigna cannot use 24 month mental health limitation to deny disability benefits
Author: Attorney Alex Palamara
Too many disability companies try to wrongfully use the 24 month mental nervous disorder limitation to deny long term disability insurance claims. How can Cigna pay disability benefits for 5 years and then claim a person should be limited to only 24 months of disability payments? In an ERISA Disability Lawsuit, a United States District Court in Oregon recently ruled that the Life Insurance Company of North America’s (LINA/CIGNA) decision to deny an individual’s continued receipt of long term disability benefits was incorrect. The Oregon Court found that CIGNA incorrectly applied the 24 month limitation for Mental Health claims in the policy and ruled that it was inapplicable to the individual’s claim.
Attorney Files ERISA Appeal Against Cigna Seeking Payment of Long Term Disability Benefits
The claimant worked as an attorney at a large law firm in San Francisco, California. Through his employment, he was covered under a Long Term Disability (LTD) Plan which provided monthly insurance benefits for disabled employees. While the policy will provide benefits for individuals whose disability is based on a mental health condition, the policy limits payments on such claims to twenty-four months.
After being diagnosed with Chronic Fatigue Syndrome, Fibromyalgia and Depression, the claimant filed an application for benefits on February 13, 2002. CIGNA promptly approved his claim the following month. From that time until 2007 (more than 5 years), the claimant received a monthly benefit of $5,000. However, on September 5, 2007, CIGNA terminated continued benefits. CIGNA based its denial under the Mental Illness Limitation. CIGNA felt that the claimant’s disability resulted from Depression rather than Chronic Fatigue Syndrome or Fibromyalgia. It is very common for disability insurance companies to argue that Fibro and CFS are mental nervous conditions, which is simply not true. The claimant timely appealed CIGNA’s decision, but unfortunately the appeal was also denied.
ERISA Disability Lawsuit Filed In Oregon Federal Court Following Cigna Appeal Denial
After the claimant had exhausted the administrative remedies, he and his Oregon ERISA Disability Lawyer (not D&S) filed a lawsuit in an Oregon Federal Court. In the lawsuit the claimant contended that his physical disabilities caused his mental health conditions which in the aggregate caused him to be unable to return to his regular occupation as an attorney. CIGNA, however, asserted that his cognitive difficulties arose from depression or a possible somatoform disorder, and, as such, the Mental Health Limitation applied. CIGNA also argued that the claimant had no physical limitations that prevented him from working his prior occupation.
The Oregon Court Finds in Favor of the Claimant and Reverses Cigna Disability Denial
After reviewing all the available medical documentation including the medical testing and the opinions of all the doctors involved, the Court ruled that the 24 month mental health limitation should not be applicable to the claimant’s case. The Court found that there was no convincing evidence that the depression, rather than Chronic Fatigue Syndrome, caused the claimant’s cognitive disability. Furthermore, the Court noted that recent Functional Capacity Evaluations found that the claimant had physical limitations that prevented him from performing the material duties of his prior occupation.
With the help of his Oregon Disability lawyer, this claimant was fortunate to be successful on his lawsuit to get back on claim for benefits. Although every case is fact specific, if you’ve been denied, please do not hesitate to contact Attorneys Dell and Schaefer for a free consultation to see how we may be able to assist you.