What Can You Do If You Receive a CIGNA Long-Term Disability Denial?
You have applied for long-term disability through an employer’s CIGNA-covered plan, but just received a letter saying your claim was denied. What should you do when you receive a CIGNA long-term disability denial?
The good news is that you can appeal that denial! Here are some things you need to know about a CIGNA long-term disability appeal.
Read Your CIGNA Denial Letter
Reading and understanding your denial letter is important. Understanding the exact reason(s) you were denied will help you figure out what you need to add to benefit your claim. Here is a list of common mistakes that often result in long-term disability denials.
Request Your Claim File
CIGNA is required by law to send you a free copy of your claim file. You also want to request your CIGNA long-term disability plan and policy. By doing this you can see what is missing from your file and you can make sure that you are meeting the definition of disability. It is important to do this before you write an appeal letter.
Write an Appeal Letter
Writing an appeal letter is a big step to appealing your CIGNA long-term disability denial. It is important to make sure you have the following included in your letter:
- Your case number
- Reason for the CIGNA long-term disability denial
- A short description of your disability
- Corrections of any errors you may have found in your original claim
- Facts as to why you believe the long-term disability denial was wrong
- Copies of your initial application as well as the denial letter and medical documentation
Stack Your Administrative Record
Stacking your administrative record means that you want to include as much medical evidence as possible to prove that you have a disability that does not allow you to perform any job. You want to include medical records from all doctors, urgent cares, and hospitals that you have been treated at for your disability. In addition, you should include information from any therapy you may have received for your disability.
You want to stack your administrative record now as much as you can. Once you submit your appeal you will no longer be able to add any other evidence.
Collect Letters from Your Doctor and Loved Ones
You may be wondering why you need a letter from your doctor if you are already submitting your medical records? The reason is that even though the medical records will show that you have seen a doctor and that you do have an injury or disability, it does not show that you are unable to work. Having your doctor write a letter explaining how your disability will affect your ability to work shows that a medical professional believes you are unable to work. This does not guarantee that you will win your case but it helps.
Having a friend or loved one write a letter, will help paint a picture of how your disability affects your daily life. For example, your neighbor can write a letter explaining that every day they help you walk to your mailbox and back. Or your niece comes over two times a week to clean your house because you are unable to bend over.
Be Certain You Are Under Video Surveillance
Insurance companies like CIGNA routinely hire someone to follow you around and record your daily activities. They are trying to prove that you are capable of doing more than you are claiming. You will be fine as long as you are following doctor’s orders and are being truthful. Just don’t be surprised if they bring up the recording.
Consider Hiring a Long-Term Disability Lawyer
A long-term disability lawyer can help you put together your appeal. They will also gather your records to stack your administrative record as well as collect letters from your doctor and friends/loved ones. An LTD will have experience with dealing with a CIGNA long-term disability denial so they know what needs to be done to put together a good case for you.
Another reason to consider hiring a lawyer that has experience with long-term disability appeals is that they will be familiar with the strict deadlines and guidelines that need to be followed.
We Know How to Deal With a CIGNA Long-Term Disability Denial
Robinson & Warncke is well familiar with CIGNA and its unique claims practices. We have successfully overturned dozens of CIGNA long-term disability claim denials.
CIGNA Has a History of Bad Claims Practices
CIGNA, through its subsidiaries, Life Insurance Company of North America (“LINA”), Connecticut General Life Insurance Company, and CIGNA Health and Life Insurance Company is one of the major insurers of long term disability benefits.
In 2009, the state insurance commissioners from the states of Maine, Massachusetts, California, Connecticut, and Pennsylvania initiated an investigation into CIGNA’s claims handling practices with respect to disability income insurance policies issued in those states. That investigation resulted in a regulatory settlement agreement (“RSA”) between the CIGNA subsidiaries and the insurance commissioners from those states in 2013.
What Are the Enhanced Claim Procedures Required Under RSA?
In addition to being required to pay approximately $925,000 in fines, CIGNA agreed to implement certain claims handling procedures to ensure a more fair, reasonable, and accurate claims process. The RSA also allows for the review of claims decisions from January 1, 2009 through December 31, 2010 (January 1, 2008 – December 31, 2010 for California) to determine whether adverse claims decisions would be impacted if the CIGNA companies had implemented the new procedures at the time of those decisions.
Among the enhanced claim procedures required under the RSA are new requirements regarding the weight CIGNA must give to Social Security disability awards, procedures regarding gathering of medical information, documentation of conclusions, and guidelines for the use of external medical resources such as independent medical evaluations and functional capacity evaluations. While federal case law is clear that Social Security disability decisions are not binding on claims administrators such as CIGNA, CIGNA had been routinely disregarding these awards without meaningful consideration.
Generally speaking, CIGNA has committed to providing more meaningful review and consideration of Social Security disability awards under the RSA, and whenever CIGNA contends that the basis for the SSD awards render them of lesser or no relevance, the CIGNA claims managers must document their rationale for that determination. Specifically, CIGNA has committed to begin making an effort to obtain the records contained in Social Security disability files that may have supported the SSA’s favorable decision provided those records are “obtainable with reasonable effort” and cooperation of the claimant.
RSA Still Preserves CIGNA’s Justifications for Denying Social Security Claims
However, the RSA preserves many of CIGNA’s favorite justifications for giving little or no weight to Social Security decisions, such as where CIGNA has more current or additional records available to it, or where the SSA has relied on factors such as a claimant’s advanced age that CIGNA is not required to consider under the terms of its policies. It remains to be seen what, if any, real impact this provision will have on CIGNA’s practices in considering Social Security awards in future ERISA disability claims.
How Will the RSA Impact CIGNA Denials in the Future?
A few of the additional requirements imposed upon CIGNA under the RSA include forwarding all of a claimant’s medical and vocational information to any medical experts who review information for CIGNA. Most of the claims review procedures are qualified by terms such as “may” in the RSA so as to provide CIGNA with wiggle room. One exception is where there is a lack of agreement between a treating physician and one of CIGNA’s internal medical resources. Under those circumstances, CIGNA has agreed that it “should” seek an independent medical examination or functional capacity evaluation.
Once again, however, CIGNA can avoid this requirement if its own medical director has reviewed the claim, performs his own separate analysis, and concludes that the position of the internal medical resource is correct after having determined that the treating provider’s opinion is not well supported by medically accepted clinical or laboratory diagnostic techniques and is inconsistent with the other substantial evidence in the claim file.
Many claimants believe that when their treating physician gives an opinion that he or she is disabled from working this should be sufficient to qualify the claimant for benefits under an LTD policy. It is well established that claims administrators are not required to follow a treating physician’s opinion. In fact, even in the RSA, CIGNA was allowed to state that vague statements of impairment by treating or certified physicians generally do not provide enough detail to make determinations about the nature or degree of functional impairment and are not binding. In light of all the vagaries contained in the RSA, it remains unclear how the RSA will impact CIGNA long-term disability denial cases in the future.
Avoiding the “Time-Concurrent” Pitfall in CIGNA Claims
CIGNA’s medical director, Dr. John Mendez, is well known to attorneys representing claimants in long term disability matters. One of Dr. Mendez’s favorite justifications for denying claims where impairments are supported by medical evidence is his assertion that the supporting medical evidence is not “time-concurrent” with the claimant’s entire period of disability. Under CIGNA policies, in order to receive benefits, a claimant is typically required to show that he has been continuously disabled according to the policy’s definitions. When accepted, this “time-concurrent” defense can pose great difficulty for a claimant.
Many, if not most, claimants first become aware of the types of diagnostic or clinical evidence needed to support a disability claim when that evidence is vaguely outlined by CIGNA in a denial letter. The denial letter may not be received until 6 months or more have passed since the date the claimant first stopped working. In Phillips v. Life Ins. Co. of North America, Case No. 1:10-cv-00064-r (W.D.K. 2011), a district court accepted Dr. Mendez’s “time-concurrent” argument where an FCE was performed six months after the disability onset date.
More recently, however, in Barbu v. Life Ins. Co. of North America, Case No. 12-cv-1629 JFB (EDNY 2014), a different court reached a contrary decision. In that case, Dr. Mendez expressed his view that in order for medical testing to be “time-concurrent” it would need to occur within a month from the date on which the claimant must prove that he was disabled. The court rejected that argument noting that CIGNA’s policy contains no requirement that the medical testing be performed at any particular time and there was no evidence suggesting that the claimant’s condition had changed over time before he obtained his FCE. The court cited numerous cases in which Dr. Mendez’s opinions had been found unreliable.
We Can Help You With a CIGNA Long-Term Disability Denial
It is critical that claimants are diligent in seeking to obtain the appropriate types of clinical medical evidence to support their claims in order to avoid the potential “time-concurrent” pitfall. Nevertheless, where this issue is raised, an experienced ERISA litigator has arguments available to minimize the relevance of the delay in most circumstances. Georgia Insurance Lawyers are standing by to assist with your CIGNA long-term disability denial.
To learn more, read our article Should I Handle My Own Appeal?
What a Long-Term Disability Attorney Will Do for You
A great disability attorney not only has experience with disability cases but will also take the time to understand your specific case. Every case is unique, and while the big insurance companies like CIGNA use similar tactics to deny, deny, deny – your specific challenges and story is the wildcard, and it’s your best asset in your claim.
Keeping You Organized and Making Sure You Meet Deadlines
In addition to framing your story, your long-term disability attorneys will keep you organized and stay within the deadlines required by law and by your insurance company (CIGNA). Deadlines are extremely important to follow when it comes to your long-term disability application and appeal. You run the risk of being denied simply by not turning in paperwork on time. Want to know more about this? Take a look at our article ERISA Appeal Basics: Timelines You Need to Know.
Part of being organized and meeting deadlines is also making sure any and all possible beneficial evidence is turned in and presented in your long-term disability case. Often this is because once you go to a hearing in front of a judge, you will not be able to present any new evidence. In the industry, long-term disability attorneys call this, “stacking the evidence.”
On the flip side, piling on reams of evidence, while potentially helpful in the future, sometimes is not the best way to initially approach a denied claim. Sometimes an insurer just has bad or missing evidence. Your disability attorney can help to figure out which medical records are missing or misunderstood. Moreover, they can help set up additional testing to demonstrate your injury makes you unable to keep up with tasks at work.
What Your Disability Attorney Will Need From You
Your attorney will want to see your denial letter along with your CIGNA policy documents. Your denial letter should state the reason for your rejection and also state the dates in which you request for appeal needs to be sent in. Remember those important deadlines? If you have difficulty getting a copy of your policy through your human resources department, you can always request it in writing from the plan administrator, meaning CIGNA.
Also, remember to present any contact information that could be beneficial to your case and collecting evidence. This includes yourself, your physician, therapists, and any other contacts that may hold important information for your case.
How Your Disability Attorney Will Protect You
Unfortunately, insurance companies like CIGNA have been known to act out of bad faith and use questionably moral practices to fight claims like yours. They can deny your benefits, unfairly, or delay them for an unnecessary amount of time. They have been known to request duplicates of paperwork at different times, even if you have already turned them in. And claim you are/were not responsive to requests for evidence as the reason for denying you. It’s a game to them! That’s why you need to stack the deck in your favor.
Also, BEWARE! While looking for an insurance attorney to help, unfair evidence can also be collected by an insurer like CIGNA. They may even go as far as collecting surveillance and chopping up the video to make it look like you’re scamming them…just to try to prove you wrong!
Learn More About How We Can Help With a CIGNA Long-Term Disability Denial
If you have been injured and are unable to continue working, we will help you present your best case to CIGNA. Contact us today.