Long-Term Disability Insurance: Denial Is Job One

Bloomfield, CTIt seems readily apparent that following closely on the heels of collecting premiums paid faithfully and consistently by policyholders, the next most-important priority of the insurance industry is to deny benefits considered to be appropriate and deserved. And in the arena of Wrongly Denied Disability Claims, the following dissertation is a classic example of the dogged determination often needed after a legitimate claim for benefits has been denied.

In this case, a claim that was denied not once, but twice by the primary insurance carrier in the saga, CIGNA Group Insurance (CIGNA).

The plaintiff in the Long term disability lawsuit had become disabled and could no longer undertake her duties as a senior systems analyst. The shopping list of her ailments included, but was not limited to, rheumatoid arthritis, osteoarthritis and de Quervain’s syndrome, which is akin to carpal tunnel syndrome.

True to form for the insurance industry, CIGNA’s first response was to deny the claimants request for needed benefits from the first benefits tier, under “own occupation.” In other words, the claimant had rightly applied for benefits citing the inability to undertake her duties in her own line of work - her own, specific occupation.

CIGNA denied her claim. She appealed; CIGNA reversed its initial denial and began to pay long-term disability benefits under the “own occupation” criteria of her policy.

Then, after a number of months, her benefits stopped coming. That’s because the claimant had reached the end of the claim window active under her “own occupation,” with her claim was now being moved - according to language in the policy - to “any occupation.” Benefits are paid under “own occupation” status for the first 24 months, then “any occupation” status thereafter, suggesting that the claimant seeking LTD benefits cannot perform any meaningful work in either her own field of endeavor or, for that matter, anything else.

As soon as her CIGNA policy pivoted from “own occupation” to “any occupation,” the benefits stopped.

CIGNA stated that in its view, while the claimant could not work as a “systems engineer,” she could work as a “project director.”

The plaintiff appealed and filed a Long term denied disability lawsuit.

As the lawsuit rolled out, it was argued that there could be no material difference between a “systems” engineer’ and a “project director,” thus the claimant could not perform either task. The plaintiff also argued that a “transferrable skills analysis,” which CIGNA used to support its denial of benefits, lacked scientific credibility and therefore would not be accepted by a federal court of law.

The plaintiff also held that a collection of forms submitted over a period of years by the plaintiff demonstrated a consistent progression of her ailments and a regression of her capacity to undertake the work, coupled with intense levels of pain suffered by the claimant - pain that was undisputed.

Finally, the bad faith insurance lawsuit argued that when closely examined, the claims filed would reveal that CIGNA’s own medical reviewers agreed that the claimant was disabled.

Benefits were reinstated.