It seems that claimants are denied long term disability benefits by CIGNA every day. CIGNA’s denials are predictable and tend to follow the same denial techniques from one claim to the next. After a LTD denial claimants are forced to go through the appeals process to get back on claim and with CIGNA it seems almost impossible to convince the appeals department to overturn an initial denial of benefits.
Such was the case with Ms. Sangha as she was left with no other option but to file a lawsuit against CIGNA in a California federal district court.
The rollercoaster ride of benefit denials and reinstatements by CIGNA
Ms. Sangha was employed by Loral Space when she suffered multiple injuries to her spine and shoulder following a car accident. She underwent surgical treatment but was left with residual pain, fatigue and depression which prevented her from returning to work. Although multiple pain specialists supported her disability CIGNA denied Ms. Sangha’s claim upon her initial claim submission. The denial was eventually overturned only to be denied again five months later. On appeal, CIGNA again reinstated Ms. Sangha’s claim following a review by Dr. Charles Brock, who agreed with the treating doctors’ assessment.
Less than two years later, CIGNA compelled Ms. Sangha to attend a Functional Capacity Evaluation (FCE), the results of which, led to another denial of benefits. This time, Ms. Sangha’s appeal was not successful.
On appeal, CIGNA requested Ms. Sangha to undergo an Independent Medical Examination (IME) performed by an occupational medicine physician, who concluded that Ms. Sangha had sedentary work capacity. A transferable skills analysis was performed relying on the evidence generated by CIGNA that identified multiple jobs that M. Sangha could supposedly perform. Relying on this evidence, CIGNA denied the appeal.
Ms. Sangha submitted a second voluntary appeal which included a two day FCE and job simulation assessment as well as a letter approving her Social Security disability application. Following two medical file reviews, CIGNA denied this appeal as well.
California Federal Court Disagrees with CIGNA
Upon review by the Federal court in the Northern District of California, the court found that Ms. Sangha’s medical records supported a finding of disability under the plan. Unlike CIGNA, the court was strongly influenced by the opinions of the treating physicians. Interestingly, the court found that the FCE obtained by CIGNA was more supportive of Ms. Sanha’s than CIGNA’s position. The IME was discounted because the doctor’s examination was limited to just three minutes of physically examining Ms. Sangha. Surveillance of Ms. Sangha documented activities that the court found were consistent with what Ms. Sangha had claimed she could do.
Despite seemingly overwhelming evidence supporting its decision, CIGNA was left with virtually nothing on which to base a winning argument.
The court overturned CIGNA’S decision.
This case exemplifies almost every tactic used by CIGNA to deny claims. Fortunately for Ms. Sangha she had substantial support from doctors who were descriptive and persistent in documenting Ms. Sangha’s debilitating pain. The doctors were very specific when listing limitations suffered by their patient including statements such as:
(1) Can only sit or stand for 15 minutes before needing to change position
(2) Can sit or stand for less than 2 hours in an 8-hour working day
(3) Needs a job that permits her to shift positions at will and to take unscheduled breaks
(4) Can “rarely” lift and carry less than 10 pounds, and can never lift or carry more than that
(5) Can only use her hands/fingers/arms for 10% of an 8-hour working day
(6) Needs to be absent from any occupation for more than 4 days per month.
In addition to the claimant having quality doctors, CIGNA made mistakes in interpreting their own FCE and relied on inadequate IMEs. Despite it all, CIGNA refused to reinstate the claim until a federal court forced it to do so. CIGNA also had to answer to a court in a jurisdiction that is arguably in the most plaintiff friendly circuit available. In the end, the right decision was made although the claimant had to fight for it.
This case was not handled by our office but Attorneys Dell & Schaefer have extensive experience dealing with CIGNA and we are very familiar with their tactics used to deny claims. If you have a CIGNA disability claim at any stage feel free to contact one of our attorneys to discuss your options.