Kentucky Court reverses CIGNA’s denial of disability insurance benefits to tradesworker

The language of a long term disability insurance plan is crucial when status of a totally disabled person is in question. The language needs to be considered very carefully. A case heard in the U.S. District Court’s Eastern Division of Kentucky, central Division in Lexington gives us another opportunity to look at how a company such as CIGNA can rely on medical information from their own doctors and fail to explain why they denied a claim. In this case the court explains why Cigna failed to provide claimant with a full and fair review in accordance with ERISA.

Claimant Ronald E. Cox came before the Court with a motion for summary judgment on the administrative record. On the other hand CIGNA Group Insurance, who is the holding company of Life Insurance Company of Northern America (LINA), filed a motion for summary judgment. Let’s see how the Court decided this issue.

Review of Background Behind Disability Claim

Cox was a 55 year old male who worked at Philips Lighting Company since November 1983 to November 2007 as a repairmen and tradesworker. After almost 24 years with the company, he left the Company due to incapacitation from neck, shoulder, leg, back and hip pain which prevented him from carrying out the duties of his job. These duties included:

He was covered by group life insurance plan which provided Total and Permanent Disability Benefits. Cox filed a claim for Total Permanent Disability benefits on April 1, 2008. As per the plan, CIGNA, as the disability insurance company, had power to determine whether he was totally and permanently disabled or not. CIGNA denied his claim for Total and Permanent Disability benefits, claiming he was still able to work for wage and profit.

Dispute arose over the denial of Cox’s benefits under the plan, so after an unsuccessful initial administrative appeals, Cox retained an ERISA disability insurance attorney. The second appeal was also unsuccessful, which led to filing an ERISA lawsuit in U.S. District Court.

Disability Attorney and Disability Insurance Company Agree on Standard of Review

During the proceedings, both parties agreed that the language of plan mandated review under the arbitrary and capricious standard. The disability attorney pointed the Court to evidence that suggested that LINA did not considered the opinions of Cox’s two treating physicians. Therefore the decision to deny him benefits was arbitrary and capricious.

First Denial of Total and Permanent Disability Benefits

LINA’s first denial of benefits was conveyed by letter to Cox. It merely emphasized the technical content of the various medical reports, without any medical analysis of these reports. While LINA mentioned results from a lumbar spinal MRI, it failed to mention the results of a cervical spine MRI which was conducted on the same day. The letter also failed to indicate that 1) the Medical Request Form and 2) the Physical Ability Assessment Form had been considered.

Instead, LINA rejected all this evidence by saying that whatever Cox had submitted did not support an impairment that precluded him from working for wages for rest of his life as terms of the policy. The company completely discounted the opinions of two doctors who had treated him for a number of years and had provided their opinions that Cox deserved his disability status.

The only evidence on which LINA denied the claim was the results reported from a functional capacity evaluation which had been conducted at LINA’s request.

Cox filed his first ERISA appeal on July 7, 2008. He included a letter from Dr. Brain Ellis, the Philips Lighting plant physician who had treated him for seven years. Dr. Ellis gave his opinion that Cox was a danger to both himself and his coworkers on the job site. The doctor supported his claim of total disability. The other doctor treating him, also backed his claim by pointing to his multilevel degenerative disc disease.

Second Denial of Total Permanent Disability Benefits

After considering a report prepared by in house Medical Director Dr. Norton Hall and a Transferable Skills Analysis report prepared by an in house expert, LINA upheld its denial of Cox’s benefits for the same reason given in the first denial on August 21, 2008.

In LINA’s second denial letter to Cox, it upheld its prior denial on the ground of lack of any medical evidence of severe impairment. The disability insurance company also expressed the opinion that Cox’s medical reports failed to reveal or to support his physical restrictions.

LINA failed to cite a letter from Dr. Thoroughman in which he described Cox’s difficulties relating to walking, balancing and driving. This letter also failed to mention the Disability Questionnaire on which Cox explained why he could not work in his own occupation or any other due to the structural weakness caused by the disc degeneration.

Cox filed his second appeal with the help of an ERISA disability attorney on November 25, 2008. He was no more successful with assistance.

Third denial of Total and Permanent Disability Benefits

Again LINA denied his claim for Total Permanent Disability benefits on the grounds that the medical evidence did not support his physical disability as defined in the policy.

In the third and final denial of his claim by LINA, the disability insurance company stated that Cox provided only a portion of the needed documentation. But this time LINA failed to mention the report of Dr. Ellis who disagreed with LINA’s second denial and explained that Cox had chronic pain and weakness in the right lower leg.

After exhausting all these administrative remedies, Cox filed suit in Boyle Circuit Court, and that action was moved to U.S. District Court on March 11, 2009.

Consideration of Total and Permanent Disability Decision by the Court

Once an ERISA disability lawsuit is filed, the role of the Court is to review the decision made by the plan administrator. As the administrator of the plan, as well as the party with ability to determine whether Cox qualified for benefits, the Court began looking for evidence in the administrative record that LINA had made a reasonable decision.

In its claims review process and explanations to Cox, LINA neither cited any physician reports that failed to support Cox’s claims, nor did LINA suggest any occupation or job which it believed Cox could undertake with his physical limitations. The disability insurance company could not give a reason for what would restrain the company from giving total and permanent disability benefits to Cox. In this LINA demonstrated arbitrary and capricious action.

The Court also emphasized the fact that the opinions of Cox’s two doctors who treated and examined him for many years was ignored, something which ERISA does not allow. The Court found that LINA’s decision to find the opinion of Dr. Hall, its in-house Medical Director more convincing (when he had failed to provide a secure basis for discounting the evidence presented by Cox’s physicians) demonstrated arbitrary and capricious behavior. The disability insurance company’s failure to address why it disagreed with Cox’s attending physicians, worked against them.

After considering the evidence revealed by the records in Cox’s administrative file, the Court found that LINA had not reached a reasonable decision when it denied him long-term disability benefits. It granted Cox’s motion in part, finding that LINA had failed to give Cox a full and fair review. LINA’s motion for judgment in its favor was denied.

Because the Court ruled that Cox had not received a full and fair review, his request for summary judgment in his favor was denied. The Court sent Cox’s claim back to LINA as plan administer to conduct a full and fair inquiry.

The Court has consistently made it clear in other rulings that disability insurance companies must give a reasoned explanation for why they have found a claimant does not qualify for coverage under their policy.

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There are 3 comments

  • Darlene,

    If you have a long term disability claim that has been denied please feel free to contact our office to determine how we may be able to assist you.

    Stephen JessupSep 20, 2013  #3

  • I too, am finding myself in this same position residing in the state of Ohio. I spent 39 years in an industry and after a battle with stage 3 cancer was deemed permanently disabled from performing my duties requiring 12 hour six day a week work schedules. Additionally, shift rotations were expected as well. Subsequently, I was diagnosed with the Epstein Barr Virus (Chronic Fatigue Syndrome). My sleep patterns have exactly no patterns whatsoever, I have many periods where I might sleep in excess of 20 hour periods without waking. Upon waking, I am still fatigued. My blood work was nearly 1400 for EBV higher than anything my physician had ever seen in her career. Yet I still stand the fight of my life to reestablish my benefits after nearly 5 months of being cut off without so much as a moments notice.

    If anyone knows who I can go to for support in fighting this in the state of Ohio, please advise me of any organizations that might assist me.

    Thank you.

    Darlene DobrolenskiSep 19, 2013  #2

  • An issue often not understood by potential consumers is what disability insurance to purchase. A lot of employees think that they are covered by employer provided disability which is governed by ERISA laws. One should realize that in almost all cases, a policy governed by ERISA is not worth the piece of paper it is written on.

    My hope is that laws should be changed to make it mandatory for the employer and disability insurance company to provide the employee a CLEAR understanding of:

    a) what is the percentage of claims that the disability insurance company has approved versus denied and continued with;

    b) what is the course to redressal of her grievances and again, what are the chances of success. This empowers the consumer to make an informed choice of purchasing insurance through employer or on her own.

    Bharma JiDec 30, 2010  #1

FAQ

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Reviews

Bruce R. (Arizona)

Steve Dell has done an exceptional job with my disability application process. The firm is extremely well managed. They have acquired an incredible amount of experience over many years. I recommend them for disability insurance claims without reservation. 

Don (Florida)

I called this firm a few months ago completely disparaged due to a company cutting off disability benefits at a time that nearly caused me to lose everything.

Attorney Alex Palmera and Danielle worked hard to reach an amicable settlement and my case was settled a few months later. This is a good firm and the specific expertise in disability claims saved me countless hours of hassle at a time when an already fragile state existed.

Thank you Mr. Palamara and Danielle.

Sandra B. (Arkansas)

I have nothing but good things to say about how my buyout was handled with my disability claim. The level of professionalism was amazing. All of my questions and concerns were answered either by Danielle L. or Alex P. in such a timely manner and with such care I would recommend them in a heartbeat to anyone needing to approach their provider with buyout options.

They did a fantastic job communicating between the provider and me, always keeping my best interest at heart and always answering my many many questions. They really did take most of the stress out of this whole situation. I would give them a 10 out of 10 for every step of this crazy journey. Thank you so much for helping me through this.

Brenda R. (New York)

I needed assistance with an appeal for a LTD claim that was initially denied. Stephen understood what needed to happen to win the appeal and he did win the appeal for me.

Michael C. (Virginia)

Greg Dell and his assistant Anneli have been extremely responsive and helpful, not only our initial consultations, but in follow-ups 1 and 2 years later with the insurance company to ensure that they comply with their agreements (which they did), as well as a separate and only slightly-related inquiry about our health insurance. I always hear back from them very quickly, which is rare and greatly appreciated.

Jeff P. (Oklahoma)

After a very long and frustrating ordeal to keep my LTD payments coming I decided to seek assistance from and attorney. After much research and asking those in the legal profession Dell & Schaefer seemed to be the top choice. I reached out and Alex Palamara was the attorney assigned to my case. All I can say is the experience was outstanding. Both Alex and his Paralegal, Danielle Lauria were excellent to work with. They were very kind, concerned, understanding of my frustrations and treated me with the utmost respect. Communication was excellent with regular updates and telling me what I could expect in each stage of the process.

Alex was also very straight forward with what to expect and no pie in the sky promises or expectations were made. In the end we won our case and I believe it was solely due to their experience and knowledge of not only the laws but the insurance companies as a whole. I would highly recommend them and am very grateful for the help they afforded to me.

Chad B. (Illinois)

I originally spoke with 3 other long term disability lawyers about my case before contacting Dell and Schaefer. None of those law firms would take it. They said the chances of me winning was not good. After finding Dell and Schaefer online I spoke with one of the attorneys that has since left. He did take my case but later it was picked up by Rachel Alters. Rachel is amazing and a very intelligent attorney. She not only won my case but also was able to get my back pay for 6 months.

I also cannot say enough about Sonia Nogueira. Sonia was always quick to answer any of my questions. I would usually hear back from her within hours of sending her a email. I do not know where I would be if I hadn’t contacted them. My family and I cannot thank them enough. Don’t let an insurance company tell you they are not responsible for paying you. I paid them for 20 years monthly and they looked for any reason they could not to have to pay me when I needed my benefit. Thank you Rachel and Sonia for all you guys do.

Paul L. (New York)

Words can only scratch the surface regarding my experience working with Attorneys Dell & Schaefer. It’s a very emotional experience making the decision to utilize disability insurance. The unknowns were/are scary. From the very first phone call, the support staff was/are very professional and reassuring. I have been working with Attorney Steven Dell for approximately 10 years. He is confident, reassuring, listens to and addresses all my concern, and is extremely dilligent in understanding my specific policies for how they impact me. It is very reassuring that Steven handles and deals with the insurance company on my behalf. Attorney Dell’s team, and specifically Merlin, Attorney Dell’s assistant, is simply fantastic. Her professionalism and attention to detail have made all my communications with the office seamless.

Simply put, my experience with Dell & Schaefer made the emotional rollercoaster experience of my neck surgery seem like a walk in the park.

Thank You, Thank You, Thank You, to both Attorney Steven Dell and to Merlin for how you have helped me over these past 10 years.

Dilligence, Reassurance, Professionalism at every step, Confidence, Results.

With 10 years experience with working with Dell & Schaefer, taking that step to call Attorneys Dell & Schaefer was one of the best professional and personal decisions I have ever made.

You want to know what you can do – the below comment about posting your first name and last name initial on our website. Put up my full name, phone number, and email address. I will gladly speak to anyone about your office and tell them my story and how instrumental Steven and Merlin have been in my life over the past 10 years.

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