CIGNA denies benefits after paying for 10 years, but Disability Attorney Stephen Jessup wins benefits for 60 year old client with fibromyalgia
Author: Attorney Stephen Jessup
For ten years our client was receiving long term disability benefits from CIGNA under an ERISA governed Group Disability Policy (Jaycor) due to a litany of medical conditions, which included Adult Onset Still’s Disease, Chronic Pain, Fibromyalgia and Fatigue. During the course of his claim and well prior to CIGNA’s termination of benefits, he had already met and passed the own occupation to any occupation definition change, had been approved for disability benefits by the Social Security Administration, and had even been approached by CIGNA on several occasions for a lump sum buy out of his policy. For all intensive purposes it would seem that at the age of 60 and the decade long history of his claim that CIGNA would not challenge the claim. However, CIGNA proved the adage that disability benefits are never guaranteed benefits.
In conducting a review of the claim, CIGNA first relied upon a paper review of the file conducted by its internal medical personnel. CIGNA’s medical personnel determined that our client’s medical records did not indicate an inability to return to work. These opinions were wholeheartedly and vehemently attacked by our client’s treating physicians. Based upon the treating physician opinions, CIGNA sent our client to a Functional Capacity Evaluation to determine his physical restrictions and limitations. Although CIGNA cited to the FCE as a basis for denying the claim, upon receipt of the claim file and review of the report, the FCE actually indicated multiple physical restrictions which would prevent him from working. CIGNA, however, only chose to cherry pick the portions of the exam, which supported its position to terminate his disability benefits. CIGNA also placed our client under video surveillance for a total of five days in a last ditch effort to justify the termination of his benefits. The video surveillance essentially only captured our client attending doctor’s appointments and then heading home, where he was not observed for the remainder of the day. It would seem that given all of the facts surrounding the claim that CIGNA would continue to pay benefits. Instead, CIGNA issued a denial letter.
Upon receipt of the denial he contacted our office to represent him for the purposes of filing an administrative ERISA appeal. Disability Attorney Stephen Jessup, a partner at Attorneys Dell Schaefer, dissected the claim file and discovered all of the glaring inconsistencies between CIGNA’s assertions in its denial letter and the actual documentation in the claim file. Mr. Jessup systematically attacked CIGNA’s position, using CIGNA’s own “evidence” against them, as well as supplementing the file with additional medical evidence in support of our clients continued disability and entitlement to long term disability benefits. The complete Appeal submitted by Attorneys Dell & Schaefer was 227 pages. Faced with an overwhelming amount of additional medical support and the realization they could not hide behind a seemingly “full and fair review” of the claim, CIGNA reinstated our client’s benefits.
CIGNA’s actions with regards to this claim are a reminder of the lengths an insurance company will go to deny benefits.