Attorneys Dell & Schaefer successfully appeal denial of benefits to claimant with CRPS/RSD
Author: Attorney Victor Peña
Ms. S contacted our firm after receiving a letter from her disability carrier, Cigna, denying her claim for short term disability benefits under her employer sponsored disability plan. Ms. S was suffering from multiple ailments including a rare, often misunderstood condition called Complex Regional Pain syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD). At the start of the claim, Cigna accepted the evidence submitted by Ms. S and her treating providers and paid two months of benefits. However, Ms. S’s condition had not improved before she received a letter from Cigna indicating benefits would not be payable beyond those two months.
Cigna denied ongoing benefits stating that “the medical information provided to date does not provide any symptoms or limitations that would prevent you from performing the duties of your normal occupation.”
The decision was reached following a file review by a nurse case manager, which is the way Cigna commonly reviews claims.
Ms. S immediately began searching for an attorney and she contacted our firm and spoke with Attorney Victor Peña who agreed to take on her case. After taking on the claim, Attorney Peña and his team requested and reviewed the claim file containing all information submitted in support of Ms. S’s claim and all information relied upon by Cigna to deny the claim. It soon became apparent that Cigna did not properly evaluate the claim. Clear support from treating physicians had been ignored without a proper explanation.
According to Ms. S’s primary care physician, Ms. S could not return to work even if accommodations were made for her. She noted that Ms. S has Complex Regional Pain Syndrome (CRPS) that is exacerbated by stress and in turn, causes anxiety and depression. Yet, Cigna chose to ignore this credible doctor’s opinions and placed more weight on the review of their internal Nurse Case Manager who had never treated or examined Ms. S.
In addition to completely ignoring the opinions of the treating physicians it appeared that Cigna’s file reviewers did not fully understand the nature of Ms. S’s disabling condition. As an often misunderstood and misdiagnosed medical condition, CRPS/RDS is a difficult condition on which to base a disability claim. There is no specific diagnostic test to identify the condition and a treating doctor will diagnose this condition based on signs and symptoms.
This reality means CRPS/RDS claims are often denied, particularly by picky disability carriers like Cigna who scrutinizes claims and looks for very specific types of evidence to support a claim – or it often seems like they are looking for a lack of evidence to support a denial of benefits.
Such was the case for Ms. S. The appeal focused on making Cigna’s reviewers understand the condition afflicting Ms. S. The appeal also focused heavily on providing as much objective clinical evidence as possible so Cigna would have nothing left to argue apart from generating its own evidence that would support its decision to the deny the claim.
The appeal was successful. Within 60 days of receiving the appeal Cigna sent a letter to our office notifying Attorney Peña that Cigna was overturning the decision to deny benefits to Ms. S. While the Short Term Disability appeal was being reviewed, Attorney Peña also submitted a claim for Long Term Disability (LTD) benefits to Cigna. Not long after the appeal decision, our office also received correspondence indicating Ms. S would be paid Long Term Disability benefits as Cigna had found she met the criteria necessary to receive benefits under the LTD policy as well.
Unfortunately, as is the case with many CRPS patients, the condition can be chronic. Ms. S continues to suffer from her affliction but our office also continues to manage her disability claim against Cigna which is still being paid.
If you have a claim or potential claim with Cigna or any other carrier and you are suffering from Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy feel free to contact our office to discuss your options.