Life Insurance Company of North America overturned previous denial of long term disability benefits for Washington Crime Scene Photographer
Author: Attorney Jay Symonds
Our client, Mr. B, formerly worked as a Crime Scene Photographer for Sherriff’s Department. In December 2012 a number of medical issues including, chronic pain syndrome, non-traumatic incomplete quadriplegia, chronic and severe neck and back pain, coronary artery disease forced Mr. B to stop working and submit his claim for disability benefits first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by Life Insurance Company of North America (CIGNA). Under his employer’s disability policies Mr. B would be considered totally disabled after 24-months if he was unable to perform the material and substantial duties of any gainful occupation, which was defined as any occupation he was qualified to perform by education, training and experience and considering any/all documented functional restrictions and limitations.
After paying Mr. B for more than 2 years under the LTD Policy, CIGNA denied further LTD benefits on the basis that he allegedly no longer met the policy definition of disability. Specifically, CIGNA determined that Mr. B “would be able to work in light occupations…and therefore [he] would be able to perform in [his] regular light occupation.” After receiving the denial, Mr. B contacted Dell & Schaefer and discussed his 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 Mr. B’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 (a) the physical capabilities assigned to Mr. B by CIGNA’s medical records reviewer were incorrect and unreasonable; (b) CIGNA incorrectly determined that Mr. B could perform his regular “light” occupation; and (c) the available medical information confirmed that Mr. B was and continued to be unable to perform his regular occupation or any other occupation. More specifically, CIGNA’s medical reviewer failed to discuss or even mention relevant medical information in an attempt to mischaracterize the significance of his complaints and purportedly support that Mr. B had light duty capabilities. Further, CIGNA’s vocational reviewer incorrectly and unreasonably concluded that Mr. B’s occupation required Light capabilities when the evidence clearly supported that his occupation required, at least, Medium capabilities. In support of this argument, Attorney Symonds retained a vocational expert who clearly established the Medium level requirements. And finally, to confirm Mr. B’s functional levels, he attended a Functional Capacity Evaluation (FCE) which clearly established that he had less than Sedentary functional capabilities.
Approximately four 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. B’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.