Due to conditions that included Polyneuropathy, Encephalopathy, Osteomyelitis, Radiculitis, and Degenerative Disc Disease with Myelopathy, a Registered Nurse of Fresenius Medical Care North America was forced to stop working in June of 2012. Luckily for her, her employer provided coverage under a Long Term Disability (LTD) Insurance policy with CIGNA should she be unable to perform the material duties of her regular occupation for 24 months and then unable to perform the material duties of any occupation for which she is qualified based on education, training or experience for the time thereafter. Although applying for benefits was nerve wrecking, her claim for LTD benefits was approved and benefits were paid by CIGNA and commenced on December 11, 2012. Shortly thereafter, the Social Security Administration (SSA) also found her to be disabled and began paying Social Security Disability Benefits. Although her Social Security Disability Benefits allowed CIGNA to pay her at a decreased amount per month as they get to offset the money she receives from the SSA, her approval for such benefits gave her a false confidence that CIGNA would continue to pay benefits until her policy expired at age 65 or until she was able to return to work.
Denial of Continued Disability Benefits by CIGNA
As mentioned above, under the terms of this LTD Policy (and most Group LTD Policies), what it means to be disabled changes after 24 months of benefits are paid. For the first 24 months, in order to qualify for benefits, a claimant must prove that he or she is “unable to perform the material duties of his or her regular occupation” and that he or she is “unable to earn 80% or more of his or her indexed earnings from working in his or her regular occupation.” After 24 months of benefits, however, what it means to be disabled changes and becomes tougher to satisfy. At that time, in order to continue to receive benefits, a claimant must then prove that he or she is “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.” Furthermore, the claimant at that time must now be “unable to earn 60% or more of his or her indexed earnings.” Thus, after 24 months of benefits, it is an “any occupation” standard with a lower threshold of earnings capacity. This is often the time when insurance companies deny continued claim for benefits.
Unfortunately for this Registered Nurse of Fresenius Medical Care North America, CIGNA denied continued benefits beyond December 10, 2014, the date in which the change in definition of disability was occurring.
Claimant Filed an ERISA Appeal on Her Own
After receiving the LTD denial letter, the Registered Nurse filed an Appeal on her own to challenge CIGNA’s decision. This 3 page appeal was followed up with 2 more pages a week later that argued that she would not be hired for the positions that CIGNA believed she could do. Unfortunately for the claimant, CIGNA upheld its decision to deny her continued claim for benefits. Within hours of receiving the 2nd denial letter, the Registered Nurse contacted Dell & Schaefer for assistance in righting this wrong.
Alexander Palamara of Dell & Schaefer Gets Involved
After speaking with the claimant, Disability Attorney Alex Palamara knew that CIGNA’s decision was wrong. It was apparent that this Registered Nurse had disabling conditions that satisfied all the terms of the policy. The new denial letter allowed for an optional 2nd ERISA Appeal or allowed the claimant to file an ERISA lawsuit. Immediately upon agreeing to take on the case, Attorney Palamara ordered the Claim File from CIGNA and updated medical documentation from her treating providers. Upon receipt of all the documents, it was clearer than ever that the objective evidence proved that she is “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 “unable to earn 60% or more of his or her indexed earnings.” Knowing that the claim file was not as strong as it needed to be and knowing that there was a high chance of success with filing an appeal, the decision was made to file a 2nd appeal instead of commencing litigation.
This 2nd appeal was timely filed. This appeal summarized all the medical records and made arguments as to why the Registered Nurse’s claim should never have been denied in the first place. On November 23, 2015, CIGNA informed us that “a determination has been made that the prior decision should be overturned.” On December 1, 2015, all the benefits that should have been paid from December 11, 2014 to that time period were paid. Although our client had not been paid for a year, she was relieved to be back on claim. She is also confident knowing that Dell & Schaefer continues to represent her as she knows it will help prevent CIGNA from denying her claim again in the future. She continues to receive her monthly benefit.
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.