How claim adjusters make their decisions to deny or terminate long term disability claims never fail to surprise and shock us. This one is so outrageous that it defies understanding.
Our client is a 52-year-old management consultant who suffers from early onset dementia, early onset Alzheimer's, degenerative disc disease, osteoarthritis, obesity, hypothyroidism, hypertension, hyperlipidemia, vitamin D deficiency, fatigue, fibromyalgia, sleep apnea, migraine headaches, depression, anxiety, TMJ disorder, and plantar fasciitis.
His long term disability insurance carrier, CIGNA, denied his claim for benefits in April 2010. We appealed the decision based on the following:
Our client's work was rapid, detail rich, and time critical, with significant amounts of human interaction in a stress-filled, fast-paced, cognitively demanding work environment. Almost every hour presented new problems and dynamics that required continuous re-thinking, re-assessment, re-grouping, and re-planning. CIGNA never did a proper vocational analysis and relied only on the physical aspects of the job. Management consultants and steel workers do not have the same physical challenges, although both require strong mental capacity and the ability to make quick and critical decisions.
CIGNA completely and utterly failed to take all of the client's physical AND mental disabilities into consideration. In another area of the law, that would be deemed bad faith.
When the initial review of records was done by CIGNA's medical personnel, not all records were available and the medical personnel were told to make a decision without the missing records. That's not just sloppy workplace behavior - that's intent to harm.
CIGNA relied on the DOT to determine that the client was not disabled. The DOT is an overly generalized and largely outdated database that does not accurately describe occupations as they exist in today's labor market. The DOT was first published in 1938 with an emphasis on blue-collar jobs. It is no longer relevant to either information and services professions, yet CIGNA still relies on it.
CIGNA failed to take the treating doctors' opinions into consideration and instead relied on paid medical consultants who had never even met or spoken with our client.
CIGNA never had our client examined in person and instead relied on three flawed and biased reviews by unqualified, in-house medical personnel and the reports of two paid consultant who did a review of records only. These consultants were contracted through IntraCorp, to do an "independent" paper review. IntraCorp, at the time our client's review was done, was a sister company of CIGNA. In recent cases, CIGNA has been chastised by the courts for using Intracorp to perform peer reviews.
The Courts have said "that the point of having a third party medical provider is for it to make independent medical judgments. If, however, it is nothing more than a captured sister company of LINA, that information could be indicative of bias in the review process." The paper reviewing doctors used in our client's claim denial have produced dozens of reports in favor of insurance companies. In fact, in more than 30 cases, these paper reviewing doctors determined that each and every claimant was not disabled. Ample proof of this was submitted with the appeal.
CIGNA's failure to conduct a proper vocational assessment, in combination with its failure to perform a proper medical review with respect to the specific duties of the client's occupation, provided undeniable evidence of CIGNA's arbitrary and capricious conduct and its failure to provide the client with a full and fair review of his claim.
Throughout the review process, CIGNA relied on selective portions of the medical records, blindly embraced the flawed findings of its unqualified in-house nurse consultants, and failed to appropriately evaluate the occupational requirements, all of which resulted in an erroneous and unfounded denial of his claim for benefits.
We submitted an appeal with unwavering support from the clients' treating physicians', a detailed job description and analysis as to why the client was disabled from his own occupation. CIGNA reversed their decision and determined that the client was disabled from his own occupation as a management consultant. He is now being paid.
Moral of the story - if your disability insurance company denies your claim, you can fight back, and you don't have to fight back alone. Call our office today at 1-877-583-2524 to learn more.
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