Recently, a CIGNA claim denial lawsuit was filed in District Court for the Eastern District of Pennsylvania by a disabled individual who was a former cop and ex security guard of the Children’s Hospital of Philadelphia through his disability lawyer. The details of the lawsuit were somewhat disturbing as it alleges how, CIGNA also known as Life Insurance Company of America (LINA), fraudulently and willfully victimized the plaintiff in its quest to rid itself of an unprofitable policy account.
The Facts of the CIGNA Disability Denial
In the case of Timothy Cumming v Life Insurance Company of North America/CIGNA, the plaintiff was a former cop who injured himself in the course of chasing a suspect. As a result of his injuries, the plaintiff took up an alternative form of employment as a security guard with the Children’s Hospital of Philadelphia (CHOP). As an employee of CHOP, the plaintiff participated in a group long term disability benefit plan out of the primary concern for the welfare of his family in the event he was unable to work anymore.
Throughout 2003, the plaintiff did his best to maintain his job as a security guard at CHOP but his previously injured right knee resulted in him having persistent and debilitating pain that affected his capacity to work. The situation was so severe that at one point the plaintiff was placed on a donor list and scheduled to have an “OATS” procedure (Osteochondral Transplant Surgery). The plaintiff’s attending orthopedic surgeon, Dr Miller noted that:
The patient’s right knee will never be normal and he is certainly disabled with the condition of his right knee.
The CIGNA claim for Short Term and Long Term Disability Benefits:
Due to his worsening medical condition, the plaintiff was forced to stop work on December 1st 2003. As the plaintiff had participated and paid the premium for coverage under CIGNA’s disability Policy from his CHOP paycheck, he proceeded to file a claim for disability benefits with CIGNA. To support his claim for disability benefits, the plaintiff completed and provided an application for disability, entitled “Integrated STD/LTD Disability Proof of Loss”. He also informed CIGNA that:
I injured my right knee in 1996 as a part-time police officer. Since that time I have had reconstructive knee surgery that failed and am awaiting and (sic) OATES (sic) procedure. This procedure is being done in order to prolong the need for a knee replacement. The constant walking and sitting causes considerable pain and swelling. I experience on a daily basis of my knee locking up.
Initially, CIGNA denied the plaintiff claim for short term disability benefits but upon appeal and with the submission of additional medical records and a letter drafted by the plaintiff, CIGNA reversed its denial and paid out short term disability benefits to the plaintiff. Later, under CIGNA’s “integrated” disability insurance policies, the plaintiff moved on to receiving long term disability (LTD) benefits from May 29th 2004 onwards.
Approximately the same time, the plaintiff also qualified for Social Security disability benefits. Upon the award of the disability by the Social security Administration (SSA), the plaintiff duly informed CIGNA of the award in line with the “Reimbursement Agreement” that governed overpayment of benefits by CIGNA. CIGNA upon notification, immediately sent notice of the Social Security award to CIGNA’s “Overpayment Recovery Team” to recoup all of its past “overpayments” from the amount of Social Security disability awarded to both Mr. Cummings and his minor children as dependents.
Problems with the CHOP’s Account
Unknown to the plaintiff, CIGNA, since 2004, had been assessing CHOP’s account for the purpose of lump sum buyouts of long term disability claims. However, CIGNA encountered problems with CHOP and the Trion Group, Inc (an important insurance broker) regarding the buyout issue. To try to resolve the settlement issue, CIGNA tried to approach CHOP in February 2006 about offering lump sum settlements to its claimants. Unfortunately for CIGNA, it was told to “hold off until the marketing is resolved” as the CHOP account was “going out to bid for 2007.” This was noted in CIGNA claim file dated February 12th 2007 which stated that:
We previously wanted to approach CHOP about settlements of their Long Term Disability claims (see below emails). Kevin Wisk had said to follow up this year to see if the environment had changed. It looks like the group cancelled as of 1-1-2007. So I wanted to check with you (or current AM) to see if there would be any problems now with settlements on CHOP LTD claims.
It was noted in CIGNA’s claim file that CIGNA was contemplating and pursuing a lump sum settlement with the plaintiff in view of the fact that he was and is a claimant under the CHOP’s account. A medical assessment was performed by a CIGNA’s own in-house medical provider, Dr Hall which concluded that the plaintiff had another 19 years more to live.
On March 2, 2007, the CHOP account manager was informed that there was just one open CHOP claim that it was looking to settle: Timothy Cummings (The plaintiff’s case). On April 6th 2007, CIGNA’s settlement specialist wrote to CIGNA’s account manager for CHOP and stated the following:
I wanted to follow up with you again on offering lump sum settlements to CHOP claimants. Typically, for a cancelled account, we do not require approval since there is no longer a reporting relationship between us and the account. However, if CHOP does have concerns about the settlement program, please let me know.
The claim file also noted on April 19, 2007 a conversation between the plaintiff’s claim adjuster and CIGNA’s in-house CHOP account manager regarding CHOP and the insurance broker, Trion:
Trion (the broker), is very defensive about what occurred in the past regarding offering settlements to CHOP claimants. “¦Trion is the largest broker in Phil, so she does not want to cause service issues. They have very high expectations. She said they feel like they requested info from us, which we did not provide”¦
Toward late 2007, CIGNA decided against offering a lump sum settlement to CHOP’s claimant and the plaintiff. It should be borne in mind that since 2002, CHOP was tagged by CIGNA as a “Consistently Delinquent Top Account” and according to the plaintiff’s disability attorney the source of seemingly “bad blood.”
It is quite apparent that CIGNA’s business dealings with the policyholder, CHOP and with Philadelphia’s top insurance broker, Trion all played a part in the handling of the plaintiff’s case. CIGNA had known from its own in house assessment of the plaintiff’s medical condition that he was “unlikely to improve”.
Concoction of a Fraudulent Scheme to deny the plaintiff of his LTD benefits
With overwhelming medical evidences that supported the plaintiff’s status and the problem that CIGNA was having with CHOP and Trion, The Plaintiff alleges that CIGNA decided to rid itself of the plaintiff’s case by concocting a scheme and basis to deny the plaintiff of his LTD benefits. From November 3rd 2008 onwards, the plaintiff was subjected to a barrage of evaluations like TSA (transferable skills analysis) and FCE (functional capacities evaluation) that would give CIGNA a basis to deny the claim. In addition, the plaintiff was subjected to unwarranted surveillance to give ground to CIGNA for claiming fraud on the plaintiff’s part. Through misleading reports, falsehoods and narrow interpretations of the medical records, the plaintiff’s LTD benefits payment was ultimately terminated in March 4th 2010.
All susbsequent ERISA appeals were denied and the Plaintiff was left with no options other than to file an ERISA lawsuit in Federal Court.