After receiving Long Term Disability (LTD) benefits for two years due to severe back conditions, a Nurse who formerly worked at Albany Memorial Hospital (which is part of the Trinity Health System) was denied continued LTD benefits after Cigna made a determination that she no longer satisfied the definition of disability under the policy.
The timing of such a denial is very common in the disability insurance world. As some don’t realize, most group disability insurance policies that are given to employees from their employers often contain fine print that states that the definition of disability (what it means to be disabled under the policy) changes after 24 months of benefits. Typically under most group policies, in order to qualify for benefits for the first two years, one most prove that he/she is “unable to perform the material duties of their own occupation.” Unfortunately, after two years, it then becomes more difficult to qualify for benefits as you now must prove that you are “unable to perform the material duties of any occupation you are qualified for based on your training, education or experience.” Insurance companies use this new definition of disability to deny many people on claim. In fact, it is the most common reason for a denial of a person on claim.
With regards to the Nurse who used to work at Albany Memorial Hospital, Cigna used the change of definition of disability as the reason to deny her claim. However, Cigna’s conclusions were blatantly wrong as there was no way that the former Nurse had the physical capabilities of performing any occupation for the rest of her life.
As justification for its denial, Cigna relied upon file reviews by its own employees. You read that right. Cigna did not have the Nurse seen by any doctor or medical professional. Cigna did not even have an outside/“independent” doctor perform a review of the Nurse’s medical records. All Cigna did was have its employee Medical Director and Claim Manager perform a review of the Nurse’s medical records. Thus, each of the people that Cigna relied upon to deny the claim had one thing in common: They were employees of Cigna and thus possessed an inherent bias in favor of the insurance company. These employees felt justified in disagreeing with the Nurse’s treating physicians who not only evaluated and treated her, but also supported the fact that the Nurse could no longer work at any occupation. Yes, these employees believed they had a better understanding of the Nurse’s conditions despite never evaluating her and not even laying eyes on her. It was what we call a purely “paper” review.
Dell & Schaefer Gets Involved and Files an Administrative Appeal
In addition to ordering updated medical records and gathering support from the many treating providers, Dell & Schaefer also had our client evaluated by a physical therapist who conducted a Functional Capacity Evaluation (FCE). The results of the FCE showed that our client had a physical demand capacity of less than sedentary work. Using this information, an appeal was timely filed. The appeal clearly pointed out the objective evidence which showed our client had the diagnoses she was complaining of. It also highlighted the years of support of the treating physicians. Lastly, it gave the results of the FCE. With this appeal, Cigna had no choice but to reapprove the claim.
Claim is Re-Approved
Roughly 3 months after the administrative appeal was filed, Cigna reinstated our client’s long term disability benefits. She is happy to be back on claim and she knows that Dell & Schaefer will do whatever it takes to keep her on claim through the maximum benefit period allowed under the policy.
If you have been denied disability benefits by Cigna or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer for a free consultation.