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.