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

Attorney Alex PalamaraAuthor: Attorney Alex Palamara

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.