Is Cigna’s Denial of Your Appeal Really a Denial?

Following the submission of your appeal has Cigna sent you a letter stating that after review of the information provided on appeal their decision to deny your claim was correct but also providing you a copy of their medical reviews?

Recent changes by the Department of Labor to ERISA regulations now require that a disability insurance company provide you an opportunity to respond to adverse information created during the course of the review of your appeal. The DOL refers to this as the “Right to Review and Respond to New Information Before Final Decision” and states in the regulatory update:

Right to Review and Respond to New Information Before Final Decision. The final rule prohibits plans from denying benefits on appeal based on new or additional evidence or rationales that were not included when the benefit was denied at the claims stage, unless the claimant is given notice and a fair opportunity to respond.

Where many disability insurance carriers simply send a copy of their medical reviews while advising you that you and your doctors have a certain period of time to respond, Cigna, confuses the matter by starting the letter by stating the denial of your claim was correct. This has been causing a great level of confusion to disability claimants who believe that their claim has been closed.

Our office is seeing a large increase of these letters from Cigna. The fact that the letter reads incredibly similar to a formal denial letter makes it easy to overlook the fact that Cigna slips in a line or two about your right to respond to the reports or their doctors (or any other adverse information) created during the review of your appeal. It is important to note that Cigna will also toll the timeframe in which it has to review your appeal – meaning as soon as they send the letter Cigna will be allowed to legally suspend the review of your claim to the earliest date that (1) you provide a response to their medical review or (2) the date noted in the letter as the deadline to respond. If a disability claimant does not pay close attention to the deadline date or the information Cigna provides it can negatively impact their ability to provide additional information in support of disability with which to win their appeal.

There are a myriad of reasons that it is most advantageous to a disability claimant to have their claim approved during the first appeal with Cigna. The ability to respond to Cigna’s medical or vocational reviews prior to the formal denial of your appeal provides you a great opportunity, but failure to respond only strengthens Cigna’s position in the event your case ends up in court. If your claim has been denied or you have received a “denial but you have a chance to respond within 30 days before we formally deny your appeal” letter please contact our office to discuss your situation. Time is of the essence.

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