This office was once again successful on behalf of a client whose disability benefits were wrongfully denied. These long-term disability benefits governed by the Employee Retirement Income Security Act (ERISA), and insured by CIGNA, have now been granted. Ms. B suffered from several conditions, including optic neuritis, sensorimotor polyneuropathy, cervical syrinx, osteoarthritis, foraminal stenosis, and cervical spondylosis, among other ailments. Ms. B had originally filed a claim for short term disability (STD) benefits, which was denied. Ms. B submitted her own appeal of the STD denial, which was ultimately unsuccessful. After exhausting her appeal rights for short-term disability, Ms. B filed a claim for long-term disability benefits, which was denied as well. At that point, Ms. B contacted our office for assistance in submitting an appeal of the adverse LTD decision. After reviewing the policy and determining she did not need to exhaust STD benefits before applying for LTD benefits, we moved forward with an appeal of the LTD denial.
CIGNA relied on the evaluation of a nurse case reviewer when denying Ms. B’s LTD benefits. It used language we routinely see in CIGNA denial letters. Specifically, it faulted Ms. B’s medical records with not including “measured range of motion (ROM) limitations by goniometry or inclinometry and/or significant muscle strength deficits by manual muscle testing.” Our office has seen this exact same language in many other CIGNA denials. Our appeal emphasized the fact that the policy did not require these specific tests in order to establish disability and that CIGNA’s denial was based on incomplete evidence and a misunderstanding of Ms. B’s medical conditions. In preparing the appeal, our office obtained additional medical records, supportive opinions of her treating physicians, and a Functional Capacity Evaluation in order to accurately establish Ms. B’s disability. Throughout the appeal letter, we presented numerous arguments and thoroughly explained why CIGNA’s denial was wrong, arbitrary and capricious.
After evaluating the evidence presented, CIGNA reversed its decision and decided Ms. B was indeed entitled to long-term disability benefits, as her medical conditions precluded her from performing the material duties of her own occupation. Our office will continue to oversee this claim for Ms. B with a goal to preventing a future denial of benefits. If your claim is denied, please contact our office before submitting your own appeal.
If you need assistance in submitting a thorough, well-prepared ERISA disability appeal, or require assistance with a claim under your private long-term disability insurance policy, please contact McDermott Law LLC.
