Fresenius Medical Care North America Employee Wins Disability Appeal With CIGNA

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.

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I was approved for LTD benefits through my group insurance carrier, but to later have my LTD benefits terminated by them as well. I felt totally defeated and devastated. My case at times, with the going back-and-forth with the insurance company was challenging to say the least, intimidating, extremely exhausting to the point there were many times I wanted to give up. My family and I determined that I needed an attorney who understood the complexity of my case, my medical condition and the various LTD and ERISA rights/laws. My family and I reached out to Dell & Schaefer to help assist me with my case, I spoke with Attorneys Dell & Schaefer about my case for an hour, they were very compassionate towards my family and I. My Attorney handled my case with the insurance company with a relentless and dogged determination. He thoroughly walked me through and explained the legal process and my options at each stage.

My attorney worked very hard on my case throughout the entire process, he took time to research and clearly understand my condition and reassure me and believed we had a chance to win my case from the start. If there were any potential roadblocks he notified me immediately. He kept my family and I up-to-date about my case, he called often to reassure me and/or check on how I was doing and to answer any questions I may have had. He was very prompt in returning calls and emails and sharing all correspondence with me from the insurance company from start-to-resolution.

My attorney’s professionalism, research and attention to detail was greatly appreciated. His perseverance and diligence was impressive. In addition, Vanessa Arriaga, was very thorough, reliable and driven to help me in every way possible. Ms. Arriaga provided outstanding dedication to my case, she provided me with prompt information in a timely manner, explained new information to me if my attorney wasn’t available, as well as if I called with additional information or questions she was patient, knowledgeable and provided personal attention and compassion.

My attorney demonstrates all the right traits a client looks for in an attorney, respect, honesty, hard work and integrity! Thank you for your helping me win my case and assisting me in the next chapter as a client.

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