Respiratory Therapist whose claim was denied without a proper review gets LTD Claim Approved after Appeal to CIGNA

A Respiratory Therapist was forced to stop working due to bilateral degenerative knee conditions which required a total knee replacement. Over time, the knee problems resulted in worsening lumbar spine problems, which required surgical intervention as well as numerous steroid injections and physical therapy treatments. The severe lumbar spine pain, as well as degenerative conditions in her knees, prevented her from performing any type of work on a full time basis. As a result, the Respiratory Therapist applied for LTD benefits and she was paid benefits for the 24 months of her disability under the “own occupation” period under the policy. Unfortunately, after 24 months the claim was reviewed by Cigna to determine if the claimant was disabled from “any occupation” as defined by her policy.

Cigna reviewed her claim for eligibility under the “any occupation” standard and ended up determining that the Respiratory Therapist was now capable of actually performing her own occupation (Respiratory Therapist-Medium level of Physical Ability Required) and, as such, Cigna decided that she did not meet the definition of disability under the “any occupation” standard. Cigna relied upon reviews by a medical director, nurse case manager, vocational rehabilitation coach, senior claim manager, and claim manager to deny the claim and indicated that the medical records revealed a “grossly intact neuromusculoskeletal” and the MRIs revealed good fusion construct with no neural compromise. Despite Cigna’s finding that she was capable of performing her own occupation, Cigna also stated, “there is insufficient evidence to support a functional impairment that would preclude you from performing sedentary occupational duties.”

Unfortunately, the former Respiratory Therapist knew that she could not work. She also knew Cigna’s conclusion was wrong. Dismayed her claim was denied and confused by Cigna’s rationale for denying her claim, she decided to find assistance with her claim and found Attorney Alexander Palamara of the Dell & Schaefer law firm.

Appeal by Attorney Palamara

After reviewing the haphazard denial letter and speaking with the former Respiratory Therapist, it was clear that Cigna’s decision was not only wrong, but that Cigna had failed to exercise any amount of due diligence in reviewing the claim and the claimant was truly unable to perform any type of work on a full time basis.

The claim file from Cigna was ordered, as well as the updated records from our now client’s treating physicians. After compiling and reviewing all the necessary information, it was clear that benefits should be reapproved since our client had overwhelming support from her primary care physician and supportive diagnostic studies which revealed problems in her lumbar spine with nerve damage. An appeal was drafted and timely filed. The appeal focused on the objective medical evidence which supported the existence of our client’s medical conditions. It also included statements of support from her primary care physician that stated why he supported his patient’s claim. This support included findings that our client: “Could not return to work even if accommodations were made to address her restrictions due to the need for strengthening, rest, and physical therapy;” “Is unable to work and is a candidate for long term disability;” and “Is only capable of occasionally sitting, standing, and walking.”

In addition to summarizing the supportive objective evidence, Attorney Palamara also showed the insurance company the careless nature of their denial mixing up the definitions of sedentary occupations with the definitions of light and medium work as well as reaching a conclusion that was contradictory to its explanation for its denial. Attorney Palamara also heavily critiqued Cigna’s failure to obtain any type of objective medical opinion regarding our client’s conditions.

Claim Approval

After reviewing our appeal, Cigna overturned its prior decision and our client’s claim was reapproved. Cigna advised that after an independent review and based on the information submitted in support of the appeal, its prior decision was wrong.

Our client received all the back benefits she was owed and continues to receive benefits, allowing her to focus on her health and rehabilitation so she can return to work in the future, if possible. Although our client knows that the fight will continue, she also knows that Dell & Schaefer will do whatever it takes to keep her on claim until she is ready and able to return to work.

If you have had a similar situation and Cigna (or any disability insurance company) has denied your claim, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer for a free consultation.

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Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Cigna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Cigna.

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Our lawyers help individuals that have either purchased a Cigna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Cigna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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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.

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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, 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.

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