Cigna Disability Insurance Policy holders often do their appeal on their own. Cigna doesn’t tell a policy holder everything they need to include in their appeal, but Disability Insurance Attorneys Dell & Schaefer will tell you what you need to know, before you file your appeal.
GREGORY DELL: Hi, I’m Attorney Gregory Dell here with Attorney Cesar Gavidia. And Cesar, in this video, I want to talk about people who have had their long-term disability claim denied by CIGNA Disability Insurance Company, also known as LINA Life Insurance Company of North America.
CESAR GAVIDIA: It’s true.
GREGORY DELL: And people try sometimes to do their appeal on their own. And the reason they do that is because when they get denied, the claim rep calls them kind of most of time in a nice manner. Customer service says, I’m sorry, but we just don’t have enough support for your claim. Can you go ahead and submit an appeal? You have 180 days to do it – 180. And then, someone else is going to – not me, but someone else is going to review the claim. And that’s because the ERISA regulations require them to do that.
So what I want to get into here is for the person who’s been denied, first off, what’s the most important thing of an appeal, number one? And then, we’ll go through some other things.
CESAR GAVIDIA: Well, in my opinion, in terms of the most important thing – and this is actually a question that they often ask the claim representative when they’re denied. Do I need a lawyer for this? And almost exclusively, in terms of the response from the disability insurers from what I’ve heard from people who have contacted us, you don’t need a lawyer for this.
GREGORY DELL: Right.
CESAR GAVIDIA: I think that’s the number one most critical mistake someone can make, is not at least consult a lawyer about that administrative appeal. And the reason for that is that people don’t realize that during that administrative appeal process, all of the supportive evidence, all of the medical records, all of the issues that you address as to why the insurance company is denying you, that’s what you’re submitting to effectively the federal judge if that case goes to litigation. That’s all the federal judge at US district court can review to determine if you’re disabled and entitled to benefits.
GREGORY DELL: Right. So what you’re saying is the rule that you get one bite at the apple to submit your appeal, and that’s it. So if the day after they make a decision on your appeal, you get hit by a bus, the court can’t consider that information, and they can only consider what’s in before.
CESAR GAVIDIA: Right.
GREGORY DELL: But getting into more detail, medical records, medical support, in my opinion, is the most important thing in any appeal.
CESAR GAVIDIA: Of course.
GREGORY DELL: For the claimant who – it’s not just send in some additional medical records, get a letter from your doctor. What’s unique about what we do at our law firm to help a person present their medical evidence versus what they could possibly do on their own?
CESAR GAVIDIA: Sure. So when we go through these extensive administrative files that we get from the insurance company, which is the first thing we request, we go through it. We comb through the entire thing looking for all of the notes, memos, reports that are generated by their in-house medical consultants.
Because it’s not truly the claim representative that makes a decision. They get the support from these physician consultants, from these medical reviewers, that go through the medical records and review the information and the evidence that you’re submitting to support your disability claim. So we have to review all of that, and we have to consider all of that, and we have to be able to address and challenge each one of those reports.
So from reviewing those reports, we know how to craft, for instance, customized disability questionnaires for the person’s doctor. We know what additional testing we may need to send that person to, like functional capacity testing or neuropsychological exam or some sort of independent medical examination that we may want to do of that person, something to dispute the findings of these people that the insurance company’s hiring to find support that the person is not entitled to disability benefits.
GREGORY DELL: Right. So I often call us quasi doctors, even though we’re not doctors and don’t give medical advice. But we know enough to help a claimant obtain the objective or the subjective medical evidence that’s going to be needed to support their claim. And the ways we do that are to guide them to the appropriate doctors, to guide them to the appropriate tests.
But most importantly, at the end of the day, it’s how we draft that custom statement, you said, and work with not just one doctor, but maybe multiple doctors that they have or an outside expert to get the appropriate medical support. And what I think is most important in the way that we do it is that we’re not just thinking about the way that the claim rep at Cigna is going to look at this particular file.
We’re thinking about how their doctor that they’re going to hire is going to look at it. Because we know that they’re going to look at it. They are the ones who are supposed to have the ultimate decision. But they’re going to rely on just what their doctor says. So we have to take it to the next level and present it in such a way that no reasonable doctor could disagree with the manner in which the treating physicians have presented the evidence.
So I think that’s key. No claimant is in a position to be able to do that because they don’t do that every day. They don’t know. They’re just worried about taking care of themselves. And the doctors are just worried about treating the patient. So you have to be very specific in how you obtain that medical evidence and how it’s presented to the insurance company.
The other thing I want to segue into is we talked about the medical, which gives you restrictions and limitations, what a person can or can’t do and why, what their diagnosis is, and what their symptoms are. How does that relate to the occupation, the vocational, and what do we do to present vocation in a disability claim?
CESAR GAVIDIA: So the vocation, or the occupation, when we’re looking at it, it’s just not a one word issue. It’s looking at what the person’s substantial material duties are of their occupation. So in most claims and most appeals, Cigna or the disability insurer is going to reach out to the employer to obtain a list of that person’s duties. And I’ve seen this many times. It’s usually exclusively what they rely on. Rarely do they reach out to the insured to find out what that person’s duties are from their perspective.
It may vary. They don’t get into the physical demands so much of the job in those employer job descriptions. So I think what’s critical is for the insured to go through a list of their substantial material duties and to explain what the physical demands of each one of those duties are or the mental and intellectual demands of that particular duty or task.
Aside from that, there’s vocational consultants that we reach out to who will do an assessment of that person’s occupation. Or, if we’re in the any occupation stage, they go through an assessment of what occupations that person may qualify for based on their education, training, and experience and, most importantly, the physical restrictions and limitations that person has.
GREGORY DELL: Right. And so the vocational expert, vocational consultant – every disability insurance company has their own in-house ones that they use to review. And they basically look at the restrictions and limitations from the doctor. And then, they do a labor market analysis or a job report study to see what jobs are available. And based upon the restrictions and limitations, could they do those jobs?
The issue is most claimants never get those reports. And the ones that do them in-house, they’re almost always the same for the claimants. So we have a network of vocational consultants all around the country, and we often get these reports for our claimants. They could cost thousands of dollars, and a claimant doesn’t want to spend the money to do that.
Since we handle all of our appeals on what’s called a contingency fee basis where the claimant doesn’t have to pay any money unless we win the claim, there’s really no risk to the claimant. And now, they have the opportunity to level the playing field by getting a vocational report done and submitting it, where otherwise, they wouldn’t be able to.
And what it is is it’s another person’s opinion. Because the vocational expert is going to take all of the medical records, review all of them, look at all the restrictions and limitations, sometimes even reach out to the doctor. They’re definitely going to reach out to the claimant and speak to them about what they can or can’t do.
And they’re going to know all about the job duties. And then, they’re going to render an opinion as to whether or not the person could do their own job or any job, depending upon what the definition of disability is at the time of the appeal. So those reports– in many cases, the vocational reports can be very helpful.
Sometimes, we don’t get the vocational expert because we do our own study. For example, we’ve had someone who works for a giant consulting firm, like a Boston Consulting or an Ernst & Young or these big, big consulting firms. And we’ll go out and do our own market study about what these jobs require and how intense they are and then give a very detailed description from working with our client to explain all the things that a person had to do day in, day out so that the claimant can really understand that.
And not only that. If the claim gets denied, again, so that the judge understands what the occupation is, not just – this isn’t just a job where you have to sit for six hours a day. And if that was the only requirement in the world, then 99% of the people in this world would be qualified for any job, regardless of educational background, training, skills, or job experience. So it’s kind of ridiculous when the companies just look at it and say, well, if you can sit, then you can do your job. Cigna often – I believe they will offer a voluntary level of appeal.
CESAR GAVIDIA: They do.
GREGORY DELL: –if you want to do one. Pros and cons of doing those. How do you make the determination as to whether or not a claimant should do one?
CESAR GAVIDIA: Frankly, most of the time, unless you have additional new evidence to submit, I forgo that and go directly to litigation. And the reason for that is, in particular, Cigna. Unless you have – unless you have something new to submit, they won’t even consider a voluntary appeal.
I’ve had Cigna tell me, we’re not going to consider your voluntary appeal you just submitted addressing all of these issues that you’re disputing for the reasons that we’ve denied the claim because you haven’t submitted any new piece of medical evidence between this date and this date. I mean, it’s completely wrong because it’s the insureds right to seek a full and fair review at every level of appeal, not just the first one.
If they’re going to offer that second one, give them a full and fair review, and let them dispute and address all of those reasons that you’re raising in your appeal denial. But unless there is some new piece of evidence, usually, if you go through a second level of appeal, you’re just opening the door to them going and reaching out to yet another doctor to support the original basis and the doctor that they’re using on the appeal to deny the claim, as well.
GREGORY DELL: Right. I think it’s –
CESAR GAVIDIA: It’s a slippery slope.
GREGORY DELL: Basically, what you’re saying – it’s a case by case analysis. And sometimes, someone does their own appeal. And then, we have to get involved and do the voluntary appeal. But often, I guess if we do the appeal – again, if they did a great job on that appeal, then maybe we do want to do a second appeal because now, we’ve got to use this opportunity to rebut something.
But if they did a really crappy job, which they often do, on the appeal review and we were to lose, then we may not want to submit another appeal because we don’t want to give them another bite at the apple to undo the bad that they did in the review.
And that’s difficult because claimants say, well, we have another chance. Let’s go for it. And then, we have to explain to them the standard of review and things like that and all of the complicated factors that go into doing another appeal.
CESAR GAVIDIA: Now, I’ve had in some cases where the insurance company will actually cite to someone else’s medical records in the appeal denial. And they offer a second level voluntary appeal. Now, you may think, well, this is great. They’ve cited to another person’s medical records.
But if you don’t address that through the voluntary appeal that they’ve opened the door to, you may not be able to bring that in as a piece of evidence in litigation because it wasn’t raised as part of the defense. Now, that’s something that they may try to argue. So, like you said, you have to take it on a case by case basis. You have to see the pros and cons and benefits to exercising that second level voluntary appeal.
GREGORY DELL: Right. I think that Cigna’s one of the world’s disability insurers. They deny a lot of claims. Probably one of the top quantity of claims we have is from Cigna denial. So many of the appeal denial letters look the same. It’s almost like, hey, look at these three denials we have. The letters almost look the same. They have their own formulas to what they’re going to do.
We know exactly what they’re going to do and how they’re going to do it. So that puts us at a great advantage to help claimants present everything and anything that they need. We’ll guide you and work with you to get you the support you need. We always offer a free initial consultation.
So if your claim has been denied, call Cesar. Call any of the lawyers in our office. We can help you anywhere in the country. We’re going to review your denial letter, and we’re going to let you know immediately over the phone whether or not we think we can assist you. We look forward to the opportunity to speak with you.