Life Insurance Company of North America (CIGNA) overturned previous denial of long term disability benefits for Massachusetts Senior Advisor
Author: Attorney Jay Symonds
Our client, Ms. G, formerly worked as a Senior Advisor for a large financial services company. In March 2015 a number of co-morbid physical conditions and ailments forced Ms. G to stop working and submit her claim for disability benefits first under her employer’s short term disability (“STD”) Policy then continuing under her employer’s Long-Term Disability (“LTD”) Policy both benefits were administered and funded by CIGNA. Under both of her employer’s disability policies Ms. G would be considered totally disabled if she was unable to perform the material duties of her regular job, which was defined as the occupation she normally performed for her employer.
After paying Ms. G for more than 8 months under the LTD Policy, CIGNA denied further LTD benefits on the basis that she allegedly no longer met the policy definition of disability. Specifically, CIGNA determined that “there was no indication that the frequency and severity of her complaints of pain were so constant that she was functionally limited or would have required any specific restrictions and/or limitations.” After receiving the denial, Ms. G contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in CIGNA’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. G’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of CIGNA’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of CIGNA’s denial. The appeal next addressed the fact that CIGNA’s medical reviewers relied on an unsubstantiated and erroneous position that Ms. G’s orthopedist’s medical assessment and opinion was not well supported by medically acceptable clinical or laboratory diagnostic techniques and that their vague claim that it was inconsistent with other unidentified (and nonexistent) substantial evidence in the file. What’s more, the medical reviewers disregarded her orthopedist’s medical opinion which was based on repeated objective medical testing (MRIs, EMG/Nerve Conduction Studies, X-Rays), repeated ineffective invasive procedures (Nerve Blocks, Steroid Injections, Radiofrequency Lesioning) and repeated in-person physical examinations of Ms. G as well as the contributing opinions of specialists in Pain Management, Neurosurgery and Orthopedic Surgery. The available medical records clearly established that Ms. G was undergoing regular treatment for her chronic medical conditions and that the objective testing conducted and multiple unsuccessful invasive procedures all supported and confirmed Ms. G’s stated restrictions and limitations. CIGNA’s medical reviewers’ oversimplification of Ms. G’s complex medical history was not the result of a full, fair, thorough and honest investigation of her claim. Accordingly, the reviewers’ opinions were fatally flawed and it was unreasonable for CIGNA to rely on them in support of its denial of LTD benefits.
Two months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records as well as the expert reports, CIGNA overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. G’s LTD claim. Attorney Symonds continues to represent our client to best ensure that CIGNA will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.