In a recent ruling from the United States District Court District of Nevada, a Judge ruled that CIGNA/LINA was wrong in denying continued Long Term Disability Benefits to Kimberly Brown.

Facts of the Case

Ms. Kimberly Brown previously worked as a Reservations Manager for VEBA, Inc. In August of 2006, Ms. Brown underwent a surgery to remove a tumor that was pressing against her brain stem. She returned to work on a reduced schedule with restrictions in February of 2007. Unfortunately for Ms. Brown, headaches and fatigue only increased while working. Her condition led her to discontinue working in August of 2007. Luckily for Ms. Brown her employment at VEBA, Inc. provided coverage under a long term disability (LTD) Policy that was insured by CIGNA/LINA. Ms. Brown filed a claim for disability benefits immediately after she stopped working. While her claim was pending, Ms. Brown underwent gamma knife surgery related to her prior brain surgery. Additionally, in support of her claim Ms. Brown submitted the records of Staci Ross, PhD, a neuropsychologist, who diagnosed Ms. Brown as having “a cognitive disorder secondary to meningioma subsequent to a resection of the meningioma.” Thankfully, CIGNA/LINA approved Ms. Brown’s claims and benefits commenced January 30, 2008, after the expiration of the Long Term Disability Insurance Policy’s elimination period.

While she was receiving benefits from CIGNA/LINA, the Social Security Administration also approved Ms. Brown for Social Security Disability Benefits. Thus the Social Security Administration also concluded that Ms. Brown was disabled. This approval allowed CIGNA/LINA to reduce the amount of money that it had to pay to Ms. Brown as the LTD policy governing Ms. Brown’s claim allowed CIGNA/LINA to “offset” certain other income benefits that Ms. Brown received.

The LTD Policy governing Ms. Brown’s claim also contained a typical “change in definition of disability.” In most Long Term Disability Group Policies governed by ERISA, what it means to be disabled will change after a set time period. Most often this change in definition occurs after benefits have been paid for 24 months. Initially, in order for Ms. Brown to qualify for benefits she had to prove that she was “unable to perform the material duties of (her) Regular Occupation” and be “unable to earn 80% or more of (her) Indexed Earnings from working in (her) Regular Occupation.” Unfortunately for Ms. Brown and for most claimants receiving benefits under a Group LTD policy, after 24 months it became more difficult for Ms. Brown to qualify for benefits. As of January 30, 2010, Ms. Brown now had to prove that she was “unable to perform the material duties of any occupation for which (she) is, or may reasonably become, qualified based on education, training or experience” and be “unable to earn 60% or more of (her) Indexed Earnings.”

Although CIGNA/LINA paid benefits to Ms. Brown after the change in definition date, they began their review and the process of gathering evidence to support a denial of benefits. For instance CIGNA/LINA set up an Independent Medical Examination (IME) by a physician of its choosing (Dr. Thomas Kinsora). Also, CIGNA/LINA had a transferable skills analysis conducted by one of its own employees. As one may imagine, Dr. Kinsora found that Ms. Brown did “not appear to have any significant cognitive limitations that would impede her ability to successfully engage in occupational activities.” This was expected considered the IME was commissioned by CIGNA/LINA. The transferable skills analysis then utilized Dr. Kinsora’s finding to conclude that there were occupations that Ms. Brown could perform that provided 60% of her indexed earnings. Armed with this “proof,” CIGNA/LINA denied Ms. Brown’s claim by letter dated November 10, 2011.

Ms. Brown timely and properly appealed CIGNA/LINA’s decision, but her appeal was denied. This lawsuit was filed shortly thereafter.

Ruling of the Court

The Court ultimately ruled that CIGNA/LINA’s decision to deny benefits was wrong. The Court was most concerned with the “Transferable Skills Analysis” conducted by CIGNA/LINA. The Court noted that the analysis ignored all of the functional barriers and accommodations that Dr. Kinsora noted that Ms. Brown would need to return to work. The Court also noted that the analysis even states that Ms. Brown could perform the duties of her prior occupation as a reservations manager which would provide her with 100% of her indexed earnings. The Court noted that Ms. Brown previously attempted to return to work and was unsuccessful, and the analysis did not take into account Ms. Brown restrictions and limitations, even those provided by Dr. Kinsora, and how it would affect her earnings at even her past occupation if she could only work part time. The Court also noted that all of the other occupations identified in the analysis do not take into account the accommodations that Ms. Brown will ultimately need. Thus the analysis did not effectively show that the “identified occupations could be performed with the accommodations Brown would require while still allowing a person to earn 60% of Brown’s indexed earnings.” The Court then ruled that CIGNA/LINA’s decision failed to establish that Ms. Brown could work in any occupation that would provide her with 60% of her indexed earnings.

If you have an active claim or have been denied benefits by CIGNA/LINA or any disability insurance provider, please do not hesitate to speak with a Lawyer at Dell & Schaefer. Disability lawyers are available at your convenience to have a complimentary phone conference.