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Dell & Schaefer Successfully Appeals Denial of Benefits to Former Clinical Therapist

Attorney Victor PeñaAuthor: Attorney Victor Peña

Mr. S contacted our firm for help fighting CIGNA after receiving a letter cutting off his benefits. He had received less than a year of benefits when CIGNA scheduled an Independent Medical Examination (IME) due to a lack of response from Mr. S’s treating physicians.

Some carriers, like CIGNA, will immediately exercise their right to schedule an IME if they request claim forms from doctors and do not receive them. In some ways this is a good thing since there are some insurance companies that merely stop paying benefits when they do not receive requested claim forms from treating physicians. Usually, when benefits are terminated, the carrier will force the claimant into the appeals process which often leads to other problems down the road. CIGNA however, rarely wastes any time scheduling an IME. The problem in this situation is the claimant is now at the mercy of the hired physician and CIGNA will rely on whatever the IME doctor reports back to CIGNA.

Mr. S failed to show up to the scheduled IME and did not respond to any of CIGNA’S attempts to reschedule the appointment. Naturally, CIGNA ceased payment of benefits. While we never recommend simply refusing to attend an IME—given the claimant cooperation provision in most disability policies—in this case Mr. S may have avoided introducing negative reports into the file since doctors hired by insurance companies are known to often serve as a basis for a denial of benefits.

Mr. S contacts Dell & Schaefer following receipt of his denial letter

Rather than submit to the IME Mr. S was able to submit the Physical Ability Assessment (PAA) forms that had originally been requested by CIGNA. Unfortunately, the forms were not enough. In June 2017, Mr. S received a letter from CIGNA stating that benefits were terminated and he had the right to submit an appeal.

Mr. S contacted our office and spoke with Attorney Victor Peña who accepted Mr. S’s case. Attorney Peña and his team immediately began working on Mr. S’s appeal. After reviewing the claim file and medical records it became apparent that Cigna had not given Mr. S a fair assessment. The medical records contained an abundance of evidence supporting Mr. S’s claim. The claim file contained documented errors by CIGNA including diagnoses that did not apply to Mr. S. It appeared the nurses reviewing Ms. S’s file had downplayed the severity of Mr. S’s condition such as describing significant spinal issues as merely a “lumbosacral sprain.”

The claim file also contained a report from CIGNA’S Medical Director that contained conclusions in complete contradiction with the available medical records. Cigna’s entire foundation for denying the claim seemed more and more unreasonable the more the file was reviewed.

To provide objective evidence of the extent of Mr. S’s functional limitations Mr. S underwent a Functional Capacity Evaluation (FCE). Unsurprisingly, the FCE revealed that Mr. Stewart’s functional ability was below sedentary, meaning that he was not only unable to perform his occupation as a Clinical Therapist but also any sit down job. The FCE report was submitted with the appeal, along with detailed physician questionnaires, a fully favorable Social Security Disability Award notice and a very detailed breakdown of the deficiencies found in CIGNA’S review.

Not long after submitting the appeal our office received notification from CIGNA that they would be overturning the denial of benefits and issuing all back benefits owed.

While Mr. S continues to receive benefits from CIGNA and continues to be represented by Attorneys Dell & Schaefer CIGNA will continue to perform similar reviews as long as Mr. S is on claim. This case is a perfect example of how easy it is for your claim to be denied despite having substantial evidence of disability. It is important to always be one step ahead of the insurance company and never let your guard down.

If you have a similar case with CIGNA or any other disability company feel free to contact our office for a free consultation.