Court Criticizes Lina For Failing to Perform Independent Examination

Disability Insurance companies are criticized often for failing to perform independent medical evaluations and instead relying exclusively on file reviews performed by in house doctors. The tendency to perform reviews in this fashion is more common with some carriers than others. Such is the case with Life Insurance Company of North America (LINA) also known as Cigna.

In Guest-Marcotte v. Life Insurance Company of North America the 6th circuit court of appeals criticizes LINA for doing this very thing.

This case involved a denial of benefits to a claimant suffering from a rare condition known as Ehlers-Danlos Syndrome (EDS) Type 3, which is characterized, most notably, by its tendency to cause joint hypermobility. The common symptoms include joint hypermobility, affecting both large and small joints; soft, smooth skin that may be elastic or stretchy and bruises easily; and chronic musculoskeletal pain.

After filing her claim for symptoms caused by EDS, Ms. Guest-Marcotte’s claim was denied by Cigna following a file review by Cigna’s in-house physician. Her appeal was also denied despite the submission of additional evidence following a review by the same nurse case manager who reviewed the claim initially and a review by another physician. The claimant also exercised her right to a second administrative appeal which was similarly denied.

Ms. Guest-Marcotte filed suit against Cigna but lost after a magistrate judge issued a report and recommendation finding that Cigna had not acted unreasonably, and the district court adopted the report.

On appeal to the 6th Circuit Court of Appeals, the decision was reversed. The critique began and focused on Cigna’s failure to exercise its option to conduct a physician examination. The court pointed out that multiple doctors had provided reports that the plaintiff could not drive, sit still or concentrate due to severe pain and so “it was not reasonable for LINA to brush aside her claims of debilitating pain without first performing a physical exam.” The court also pointed out that since the diagnosis of EDS was accepted without question, if Cigna disbelieved the claimant, how could it be logically possible to deny the treating doctors’ observations in the absence of contrary observations?

Since the diagnosis was undisputed, and the condition is known to cause frequent joint dislocations and chronic pain, the court found LINA’s denial without conducting a physical examination arbitrary and capricious. The court remanded the case back to LINA so it could “conduct a deliberate and principled review of Guest-Marcotte’s claim.”

While this claimant was successful in getting her claim remanded back to Cigna for an additional review it should be noted that Cigna already performed three separate reviews of Ms. Guest-Marcotte’s claim and the court is simply giving Cigna another opportunity to review again, albeit with instructions to perform a physical evaluation of Ms. Guest-Marcotte.

Just as important is the fact that the court distinguished this case from other cases where it is difficult to diagnose the condition, such as fibromyalgia or back pain. Courts have upheld claim denials in the 6th circuit as well as others where the claims administrator did not perform a physical evaluation and relied primarily on in house file reviews.

This case was not handled by our office, but we think it can be beneficial to those struggling to obtain long-term disability benefits. If you have any questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free case evaluation.

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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.

Sandra B. (Arkansas)

I have nothing but good things to say about how my buyout was handled with my disability claim. The level of professionalism was amazing. All of my questions and concerns were answered either by Danielle L. or Alex P. in such a timely manner and with such care I would recommend them in a heartbeat to anyone needing to approach their provider with buyout options.

They did a fantastic job communicating between the provider and me, always keeping my best interest at heart and always answering my many many questions. They really did take most of the stress out of this whole situation. I would give them a 10 out of 10 for every step of this crazy journey. Thank you so much for helping me through this.

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I needed assistance with an appeal for a LTD claim that was initially denied. Stephen understood what needed to happen to win the appeal and he did win the appeal for me.

Michael C. (Virginia)

Greg Dell and his assistant Anneli have been extremely responsive and helpful, not only our initial consultations, but in follow-ups 1 and 2 years later with the insurance company to ensure that they comply with their agreements (which they did), as well as a separate and only slightly-related inquiry about our health insurance. I always hear back from them very quickly, which is rare and greatly appreciated.

Jeff P. (Oklahoma)

After a very long and frustrating ordeal to keep my LTD payments coming I decided to seek assistance from and attorney. After much research and asking those in the legal profession Dell & Schaefer seemed to be the top choice. I reached out and Alex Palamara was the attorney assigned to my case. All I can say is the experience was outstanding. Both Alex and his Paralegal, Danielle Lauria were excellent to work with. They were very kind, concerned, understanding of my frustrations and treated me with the utmost respect. Communication was excellent with regular updates and telling me what I could expect in each stage of the process.

Alex was also very straight forward with what to expect and no pie in the sky promises or expectations were made. In the end we won our case and I believe it was solely due to their experience and knowledge of not only the laws but the insurance companies as a whole. I would highly recommend them and am very grateful for the help they afforded to me.

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