In the case of Lapidus vs. Life Ins. Co. of N. Am. a Missouri federal court ruled against Cigna finding that Cigna wrongfully terminated long term disability benefits to Lapidus after having initially approving her claim for benefits. Prior to filing for disability benefits Lapidus worked as the vice-president of medical benefits for BJC Healthcare. Despite having undergone a spinal fusion and additional conservative treatment measures she experienced chronic back problems that resulted in her only being able to work in a reduced capacity. Under the terms and conditions of her employer’s disability policy with Cigna she made a claim for short and then long term disability benefits.
Cigna approved both her short term disability benefits as well as the long term disability benefit following the cessation of short term. However, the long term disability payments were short lived. After only eight months of payments Cigna advised Lapidus that it had found she was no longer considered disabled under the terms and condition of the policy. The denial was predicated on internal medical reviews that deemed a lack of evidence to support ongoing restrictions and limitations. Lapidus appealed Cigna’s denial and in doing so argued that there was nothing in her medical records to suggest that her condition had improved to a level that would allow her to return to full time work duties. Cigna ultimately upheld the denial of her claim and a lawsuit was filed in federal court.
Important to the Court’s ruling was the fact that the Court reviewed Lapidus’s lawsuit under a favorable de novo standard of review, which means the Court was only tasked with determining whether it believed Lapidus was disabled or not. This is an extremely favorable standard of review as opposed to the “arbitrary and capricious” standard of review found in the overwhelming majority of ERISA governed employer provided disability plans. In reviewing the facts of the case and reviewing relevant case law, the Court observed:
An insurer who first approves LTD benefits, then later terminates them, must show a “significant” change in claimant’s condition making her no longer eligible for benefits.
The Court relied on Lapidus’s doctors reports as well as gave significant weight to the results of a functional capacity examination, which indicated restrictions and limitations that would preclude Lapidus from performing the duties of her occupation. Additionally, the Court believed that Lapidus’s medical history to include her course of medication, surgical history, injections, spinal cord stimulator implantation, and objective diagnostic medical tests all supported the level of pain that Lapidus was experiencing.
The Court’s ruling was predicated on a straight forward evaluation as to whether Lapidus’s medical condition at the time of the denial was so different from the period of time in which Cigna had approved benefits to justify her benefits being terminated. The Court found it was not. The Court ordered Cigna to pay disability benefits owed top Lapidus but denied a motion for attorney fees filed by her attorney.
What can we learn from this decision?
As noted above, the Court reviewed Lapidus’s claim under the favorable de novo standard of review. Had the claim been subject to an Arbitrary and Capricious standard of review the outcome could have been much different. Additionally, although the Court found in Lapidus’s favor it must have not found Cigna’s conduct to be too egregious as evidence by the fact that it denied Lapidus’s attorney’s motion that Cigna pay her attorney fees.
The Court provided common sense arguments based on applicable case law and gave examples of what information a Court will consider when determining disability and the importance of strong corroborating evidence to support complaints of pain.
It is clear from reviewing court decisions that many cases do not turn out as favorable as this one. For this reason it is imperative that an insured gather and provide as much evidence in support of his or her claim for disability benefits to not only stand the best chance in Court but to avoid having to leave their financial future in the hands of a court in the first place.
Our firm had no part in Lapidus’s claim but feel it is important to report on pertinent Court ruling to better inform insureds who may be experiencing similar circumstances.
If your claim for disability benefits has been denied or you have questions regarding your claim please feel free to contact our office and speak to one of our disability insurance attorneys.