Our eventual client began working as a 3rd Grade Teacher in the State of Maryland in August of 2010. Due to her employment with the Board of Education of Washington County, she was covered under a long term disability insurance policy that was administered and underwritten by the Life Insurance Company of North America (“Cigna”). This long term policy was to provide her with a percentage of her prior monthly earnings should she be “unable to perform the material duties of her regular occupation” as a teacher.
Because our client suffered from a host of sicknesses, she was forced to stop working and make such a claim in May of 2013. Her sicknesses included: Crohn’s Disease, Idiopathic Inflammatory Bowel Disease, Abdominal Pain, Diarrhea, Nausea and Vomiting, Chronic Pain Syndrome, Fibromyalgia, Arthralgias and Myalgias, Extreme Fatigue, Gastroesophageal Reflux Disease (GERD), Mixed Connective Disorder, Hepatitis, Major Depression, Adjustment Disorder with Depressed Mood and Anxiety.
Within days of stopping work, she applied for and was initially approved for Long Term Disability (“LTD”) benefits by Cigna. In almost record time, Cigna agreed on June 12, 2013 that benefits should be approved and informed her that benefits would commence on August 7, 2013 after the expiration of the elimination period.
Benefits were paid from August 7, 2013 through September 24, 2014. Unfortunately for our eventual client, she received a letter dated September 25, 2014 which informed her that Cigna had made a determination that it was “unable to continue paying benefits beyond September 25, 2014.” Cigna based its decision on “paper” reviews that were conducted by its own employees such as the Claim Manager, Senior Claim Manager, Nurse Case Manager and Medical Director.
“Paper” reviews mean that these people never met with, evaluated or even laid eyes on our eventual client. These individuals merely reviewed the medical records of our client and made a determination as to whether she continued to satisfy the definition of disability. As one might expect, when all the “paper” reviewers work for the insurance company, a certain level of bias is present in the decision making process. And as one may expect, these employees for Cigna all determined that the 3rd Grade Teacher should no longer qualify for disability benefits.
The Hiring of Dell & Schaefer
After waiting for over 3 months, our eventual client contacted Attorneys Dell & Schaefer and spoke with Attorney Alexander Palamara on January 7, 2015. Attorney Palamara requested that she immediately send him the September 25, 2014 denial letter as time was of the essence to challenge Cigna’s decision to deny.
A quick look at the denial letter easily revealed the inconsistencies and ineptness of Cigna’s reviews and decision. After speaking with our eventual client, there was no question that due to her various disabling conditions she should continue to satisfy the definition of disability under the Policy governing her claim. Within hours of the initial consultation, Dell & Schaefer agreed to take on her case and to fight to get her back on claim.
Review of the Claim and the Filing of the Administrative Appeal
Immediately upon taking on the case, Attorney Palamara ordered a complete copy of Cigna’s file so that he could analyze the reviews conducted by Cigna and so that he could assess the proof of loss our client previously provided to Cigna. Our review of these records showed that Cigna’s reviews were weak and that the medical records and support of her treating physicians were quite strong.
After the review of the pertinent material was completed and updated medical records received, a timely administrative appeal was filed for the purpose of overturning Cigna’s previous decision. This appeal focused on the objective evidence found in the medical records that overwhelmingly supported that our client continued to be “unable to perform the material duties of her regular occupation” as a teacher. Our appeal also noted errors in the paper reviews of Cigna’s employees.
By way of a letter dated May 21, 2015, we received word that Cigna had made a determination that “the prior decision should be overturned.” As such, our client’s claim was being reinstated and all past benefits were to be paid immediately. Our client and our firm were very pleased that Cigna had decided to correct its previous error. Although we are happy, we are not content as the fight will continue. Our client knows that after 24 months of benefits are paid, what it means to be disabled changes under her policy. At that point we will have to prove to Cigna that she is “unable to perform the material duties of any occupation for which… she may reasonably become qualified based on education, training or experience.” At that time, because it becomes more difficult to qualify for benefits, an additional fight may begin. However, our client knows that we will do whatever it takes to see that she remains on claim until she is ready and able to return to work or until her policy expires at age 65. If you have been denied disability benefits by Cigna or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.