Janet (not her real name) had a Cigna short-term disability claim, but just one month after receiving her first check, Cigna required Janet to apply for Social Security benefits and they hired a “neutral” company to help her with the process.“By October of 2012, my disability benefits had rolled into LTD and to my amazement, by January, I was approved for social security,” says Janet, who has worked for many years as a nurse in a major hospital. She suffers from facet joint disease, which can cause disabling back and neck problems.
“My job requires me to walk a lot and that caused my back problem,” she says. “It got so bad that I couldn’t stand or sit for any length of time and I couldn’t finish an 8-hour shift. The hospital offered me an early retirement so I took it, figuring I would get well soon and find another job. And my Cigna representative told me that I still qualified for LTD, even though I was unemployed.”
Janet received her first Social Security disability check in February and Cigna continued to pay her benefits, minus the amount received by Social Security. But just four months later, Cigna cut her off.
“Cigna had received a letter from a doctor who said there was nothing wrong with me and therefore I was disqualified from long-term disability,” says Janet. “I found out that Cigna had investigated me and determined I was not eligible through my primary care doctor. She asked me how my LTD was working out and showed me an internal memo. She had received a message from a doctor on the East Coast asking for her opinion about my disability, but by the time she returned the call, they said it was too late and the case had already been settled!”
Janet had never even heard of this doctor on the East Coast but with her own doctor’s help, she tracked him down and phoned the East Coast doctor’s clinic. “They said it wasn’t their fault because when Cigna gives them medical reports they only have 24 hours to ‘solve the case,’ meaning they do an independent medical review,” Janet explains.
As well, while Janet was under investigation - from February until June of last year - Cigna changed her case manager. She believes it was because he was too helpful.
“My first case manager was wonderful. He explained that Cigna would request documentation from me based on my ‘functional capabilities’ so I didn’t send them much information,” she says.
Janet’s new case manager needed to determine her level of functionality but didn’t explain to her what that meant, except that her doctor would fill out a medical report stating how much she could lift when she returned to work. But Janet’s disability had nothing to do with lifting - she wasn’t able to stand or sit, and that issue wasn’t on the medical form. She wrote to Cigna, asking them to define her ‘functional capacity’ but they replied by terminating her benefits.
Janet appealed - twice. The third time she contacted Chris Roy, an attorney who specializes in Oregon disability and Washington long-term disability insurance cases. “Chris gathered my records and he contacted Cigna immediately,” Janet says.
“We worked together to present my case with a third appeal and does he know the law!”
Roy explains that most insurance companies only allow one appeal, but in Janet’s case they offered a second appeal. “This was very fortunate, because her claim file was incomplete, and it gave me an opportunity to gather the necessary evidence and present it in the right way.”
Roy also points out that insurance companies such as Cigna often use the “independent medical review” (“IME”) as the rational and basis for denying long-term disability claims.
“Of all the inequities in the disability insurance claim management, the IME ranks as one of the most egregious,” says Roy. “In truth, there is nothing ‘independent’ about these reviews. Insurance companies hire board-certified nurses and doctors to conduct a pure paper review of claim files, and come to an expected result. These medical professionals pretend to confer with the claimant’s treating doctors, but I’ve never seen an instance where a conversation actually took place.”
Roy not only won the appeal for Janet and monies to cover benefits back to June of last year, he also received from Cigna disability payments until October 2014 - which covers two years as per Janet’s policy.
“I wouldn’t have gotten anywhere if not for an experienced disability attorney like Chris Roy,” Janet adds. “I was surprised that I was paid until October, even though I believe I had every right to benefits. But how does Cigna know that I am unable to work until October and how do they know my condition won’t worsen?”
Cigna paid Janet for two years as long as she is disabled from her “own occupation.” At the two-year mark, Janet has to prove she is disabled from “any occupation” from which she can earn at least 80 percent of her previous salary,” Roy explains. “And it becomes more difficult for her to receive benefits after the two-year mark. So Cigna decided to prepay her benefits and at the same time, deny continuing her benefits after October 2014. Janet has 180 days from the date of denial to appeal that decision, so she is essentially on the clock. Under the law, if she fails to appeal by the deadline, she is barred from bringing a lawsuit in court, so it is imperative that she appeal in time. Probably one of the reasons they decided to prepay and deny early was to start the clock ticking, and hope that she misses her appeal date.”
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Jeanine Mercer
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