Disabled Vessel Captain for Marine Services Corporation Wins Long-term Disability Appeal With CIGNA
Author: Attorney Cesar Gavidia
Growing up on the coastal waters of Louisiana it was only natural for Chance to pursue a career on the water. Before joining BMSC as a Relief Captain, Chance had worked on the water either piloting boats or as a tankerman loading and discharging barges. By the time he began working for BMSC he had over 30 years of experience working on the water and specifically on large vessels like freighters and barges.
By 2011 congestive heart failure, peripheral artery disease, uncontrolled hypertension, uncontrolled diabetes type 2, bilateral lower extremity neuropathy and other health issues had taken their toll on Chance, causing him to file for disability through his employer’s long-term disability plan with CIGNA.
Upon receiving Chance’s claim application, attending physician statement and medical records supporting his total disability from his own occupation as a Relief Captain, CIGNA approved and began making monthly disability insurance benefit payments.
CIGNA’s Decision to Terminate Benefits on Unclear and Vague Grounds and Disregards Award of Social Security Disability Benefits.
Chance received benefits just shy of 24 months for total disability in his own occupation as a Relief Captain before CIGNA informed him that they would no longer continue to pay his claim. CIGNA’s basis to terminate Chance’s long-term disability claim when his condition had only clearly worsened was at best unclear and vague, but best described as egregious and unconscionable.
As its basis to deny his claim CIGNA reasoned that “no clinically measurable testing [existed] on file for [them] to review regarding a decrease in [Chance’s] functionality to support impaired functional capacity.” It also claimed that Chance’s treatment provider provided no details in regard to the extent of his impairments, which begs the question that if indeed this were true, then on what basis had CIGNA approved and paid benefits for the preceding 24 months?
In its letter explaining its basis for terminating Chance’s long-term disability claim CIGNA also recognized that Chance had been awarded social security disability benefits by the Social Security Administration, however, claimed, without actually citing any direct evidence, that the Social Security Administration had not recently evaluated him or requested medical information regarding the continuation of his SSDI benefits – as if CIGNA had based its denial on some recently found discovered piece of medical evidence.
Attorney Cesar Gavidia and Appeal Team at Attorneys Dell & Schaefer Prevail in Overturning CIGNA’s Decision to Terminate Benefits.
In their Appeal to CIGNA, Attorney Cesar Gavidia and his appeal team at Dell & Schaefer addressed all of the flaws in CIGNA’sdecision to terminate benefits. The Appeal highlighted that as recently as 6 months prior to CIGNA communicating its decision to terminate benefits, CIGNA had contacted Chance to inform him of the change in occupational definition from “own occupation” to “any gainful occupation”, and that at that time Chance had informed the CIGNA representative that he had recently had 2 surgeries on his legs to improve circulation and that he had recently been hospitalized for 4 days due to congestive heart failure. He informed them that his legs were “completely shot” and that they were constantly numb and causing him to fall.
Just five months prior to his denial Chance again spoke with CIGNA and explained that he had no feeling in his legs and that he was still suffering complications due to congestive heart failure and that the surgeries on his legs had failed.
Attorney Gavidia and his team described in their Appeal how CIGNA ignored the volume of overwhelming medical evidence; how CIGNA failed to ever even have Chance examined by a qualified medical physician; and the nature in which CIGNA minimized the angiograms and stents performed on Chance to save his life. It was clear that CIGNA failed to fully investigate the full extent of Chance’s restrictions and limitations, and they never truly considered the true physical demands of his occupation as a Relief / Ship Captain.
Within one month and two weeks of receiving the Appeal CIGNA overturned its decision to deny the claim. CIGNA has continued to pay Chance’s long-term disability claim, however, has also continued to request periodic updates from Chance and his treating physicians, which Attorney Gavidia helps Chance promptly address.