Disability Benefits Reinstated: Dell & Schaefer Appeal Gets CIGNA to Admit its Decision to Deny was Wrong
Author: Attorney Alex Palamara
A former PACE Site Manager for Sentara Healthcare contacted our office after being referred to us by her Social Security Disability Attorney. After 4.5 years of being on claim, out of nowhere CIGNA denied her continued long term disability (LTD) benefits. She came to us after an appeal she filed on her own had been denied. Fortunately, the LTD Policy governing her claim through Sentara Healthcare allowed her the option of filing a second appeal.
Our client was forced to stop working in December of 2010 due to a laundry list of medical conditions. Her disabling conditions included: Systemic Sclerosis, Raynaud’s Interstitial Lung Disease, Fatigue and Malaise, Pulmonary Hypertension, Tachycardia, Cardiac Arrhythmia, Hypertension, Left Lower Extremity Deep Venous Thrombosis times 2, Bilateral Lower Extremity Chronic Edema, Bilateral Lower Extremity Leg Pain, Bilateral Lower Extremity Diminished Motor Strength, Rheumatoid Arthritis, Lumbar Spine Degenerative Disc Disease, Lumbar Spondylosis, Severe Right Foraminal Stenosis at Multiple Levels, Congenital Caudal Bony Canal Stenosis, Low Back Pain, Multiple Joint Pain, Diabetes Mellitus Type II, Shortness of Breath, Asthma, Morbid Obesity Status Post Gastric Bypass Surgery, Anemia and Depression.
As one might imagine, with this many issues, not only would she be expected to be unable to perform the duties of her own occupation, but it is reasonable to believe that she is unable to perform the material duties of any occupation for which she is, or may reasonably become, qualified based on education, training or experience. Unfortunately for her, after being paid benefits from June 9, 2011 through December 24, 2014, by way of a denial letter dated November 25, 2014, continued benefits were denied as CIGNA found that “an explanation of your functionality and how your functional capacity prevents you from continuously performing the material duties of any occupation are not clinically supported.” In support of this decision, CIGNA relied upon an “Independent” Functional Capacity Evaluation it had arranged which apparently showed that she was able to perform a sedentary occupation. Using the results of this evaluation, CIGNA denied continued benefits.
With this initial denial letter in hand, our client quickly filed an appeal on her own that merely stated “I am requesting an appeal regarding my long term disability, as soon as possible.” Three months later she followed up her appeal with limited medical documentation showing that she would be unable to perform the occupations that CIGNA stated she should be able to perform in the denial letter.
Her appeal was unfortunately denied by way of a 2nd denial letter dated January 20, 2015. With the latest denial letter, CIGNA relied upon a medical review by an Occupational and Internal Medicine Physician, surveillance footage and the previous Functional Capacity Evaluation.
Alexander Palamara of Dell & Schaefer Gets Involved
Within hours of being contacted, Attorney Palamara reviewed the denial letter and relevant medical records provided. Although time was extremely limited to file the 2nd appeal (only 60 days remained), we knew from what our client told us that we would be able to make a strong argument that CIGNA’s previous decisions to deny benefits were wrong. In fact, we believed that we would be able to show that the former PACE Site Manager for Sentara Healthcare would be unable to work ever again.
Review of the Claim File
After reviewing the claim file, we knew that the reviews relied upon by CIGNA were unreliable. Furthermore, the medical records we gathered showed objectively why our client should continue to receive LTD benefits. An administrative appeal challenging CIGNA’s ultimate determination was timely filed. The appeal questioned CIGNA’s reviews, evaluations and surveillance and pointed out that the overwhelming objective evidence found in our client’s medical records easily demonstrated her satisfaction of what it means to be disabled under the policy.
CIGNA Reinstates LTD Benefits
Within 90 days of the appeal being filed, CIGNA contacted our office and informed us that the denial of LTD benefits was being overturned. Our client is now receiving LTD benefits on a monthly basis.
Although she went without benefits for over a year, our client is happy to be back on claim. With the continued representation of Dell & Schaefer, she is confident that her benefits will continue for the life of her claim as she knows that we will do whatever it takes to keep her on claim. 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 & Schaefer for a free consultation.