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Federal ERISA Lawsuit Filed Against CIGNA Following Its Decision to Terminate the Long-term Disability Claim of an Insured Suffering from Severe and Chronic Lower Back Pain

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Mr. V had previously worked as a project manager for the YMCA until severe and chronic lower back and radiculopathic pain caused by sciatica, lumbar radiculitis, degenerative disk disease and osteoarthritis forced him to cease working and file a long-term disability claim under his employer’s long-term disability insurance plan funded and administered by CIGNA.

According to the National Institute of Neurological Disorders and Stroke, 80% percent of adults experience low back pain at some point in their lifetimes and is the most common cause of job-related disability and a leading contributor to missed work days. Both men and women are equally affected by low back pain and it can range from a dull, constant ache to a sudden, sharp sensation that leaves the person incapacitated. If back pain persists for 12 weeks or longer it is defined as chronic. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. In some cases, treatment successfully relieves chronic low back pain, but in other cases pain persists despite medical and surgical treatment.

In Mr. V’s case, he had suffered with low back and leg pain for years, until he reached middle age and the pain and discomfort began affecting his productivity and attendance at work. The pain eventually became constant and would radiate to his hips and down to his foot. He had difficulty standing for periods of time and experienced limited range of lumbar motion. In attempts to relieve his pain he tried everything from medications to injections and physical therapy, however, nothing worked.

CIGNA Approves First 24 Months of Own Occupation Disability

Shortly after submitting his disability claim, CIGNA approved Mr. V’s benefits and accepted that he was disabled from his own occupation as a project manager. Mr. V’s long-term disability plan with CIGNA insured him in his own occupation for the first 24 months of disability. The policy required that in order to qualify for benefits, the employee must be unable to perform the materials duties of his or her Regular Occupation; and be unable to earn 80% or more of his or her Indexed Earning from working in his or her Regular Occupation.

After 24 months of benefit payments the definition of Disability changed to “any occupation”. In other words, in order to remain eligible the employee must be unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and be unable to earn 60% or more of their Indexed Earnings.

As part of its evaluation into whether Mr. V was disabled from any occupation, CIGNA conducted a transferrable skills analysis, which concluded that Mr. V could perform four different occupations, none which he had ever worked in before, nor were consistent with Mr. V’s education, training or experience. Based on the results of the transferrable skill analysis, Mr. V’s claim was terminated.

Mr. V submitted his first appeal on his own, thinking that after being on claim for so long CIGNA’s decision must have been a mistake or oversight which he could fix with a strong letter from his doctor, a functional capacity examination and submission of more medical records. Unfortunately, the submission of the report from the functional capacity examination, the letter nor the records produced the result he was hoping for and CIGNA promptly denied his appeal.

Following the denial of his first appeal, Mr. V contacted Attorneys Dell & Schaefer and hired Attorney Cesar Gavidia who promptly took over the case. Attorney Gavidia discovered that during the course of the first appeal, CIGNA placed Mr. V under video surveillance and had Mr. V’s file reviewed by a peer review physician who frequently conducted reviews on behalf of disability insurance companies. Unsurprisingly, the peer review physician hired by CIGNA attacked the reliability and validity of the FCE submitted with Mr. V’s first appeal. Attorney Gavidia decided to exercise Mr. V’s second voluntary appeal in order to attack the credibility of CIGNA’s peer review physician as well as CIGNA’s arbitrary denial of the claim. As expected, CIGNA denied the second voluntary appeal, choosing to stand by its peer review physician.

Federal ERISA Lawsuit Filed Against CIGNA For Wrongful Denial of Long-term Disability Benefits and Violation of Federal Law.

After exhausting all of the administrative remedies required under Mr. V’s long-term disability plan, Attorney Gavidia filed a lawsuit in federal court against CIGNA alleging that the disability insurance company violated ERISA by unjustifiably terminating Mr. V’s long-term disability insurance benefits causing him irreparable harm. In addition to demanding that CIGNA pay all benefits owed under the plan, the lawsuit requests that CIGNA pay Mr. V’s attorney fees and costs. Mr. V’s case is currently pending in U.S. District Court with trial scheduled to commence within the next 16 months.

Read more about CIGNA disability claims.

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