Our client, Ms. W, enjoyed a long and successful career as an office manager for a mid-size company. Unfortunately, shortly after receiving a promotion, she began to experience unusual and troubling symptoms such as extreme fatigue, severe pain in her joints, fogginess and confusion, and severe headaches. Originally, she dismissed her symptoms as being run down, a lack of sufficient sleep, and stress. However, overtime, her symptoms progressed and began to significantly interfere with her home and work life. She started missing work due to her fatigue and chronic pain, something she rarely did. She had difficulty concentrating at work, forgot coworker's names and appointments, and lost her train of thought while reading or conducting meetings. She was always exhausted. There were days that she could not get out of her bed and the pain was so severe that it hurt to grip anything, making it difficult to button her shirt, comb her hair, or cook a meal. She often could not walk her dog and had to have a friend come by to help her. Ms. W.'s physicians ran multiple tests, but a diagnosis eluded them. Ultimately, she went to a rheumatologist and was diagnosed with fibromyalgia, through the exclusion of other conditions and positive findings on a tender point examination.
Ms. W. tried various medications, but her debilitating symptoms remained. Eventually, Ms. W. could no longer maintain employment and filed for disability insurance under her employer sponsored policy with Cigna. After a long process, Cigna approved her claim. Thereafter, periodically, Cigna would discontinue benefits because it alleged that it did not receive a required form from Ms. W. or her physicians, despite proof of receipt. However, Ms. W. remained on claim for approximately 7 years.
During her claim, Cigna required Ms. W. to apply for Social Security disability ("SSDI") benefits. She was approved after a hearing with an administrative law judge, who determined that she was unable to maintain gainful employment in any occupation due to her severe fibromyalgia. Ms. W.'s physicians continued to opine that she remained unable to work due to her severe and chronic condition. However, without warning, after 7 years, Cigna denied her claim and terminated her monthly disability payments. Cigna claimed that there was no longer objective proof of Ms. W.'s disability. Left with only her meager SSDI benefits, Ms. W. feared that she would lose her home and be unable to pay for her medications and treatment. Facing financial devastation, she tried to prepare an appeal of the decision on her own, by asking her physician to send in another Attending Physician Statement. However, understanding that Ms. W. had only one opportunity to appeal this decision and that disability claim appeals typically require significant information to be successful, her physician strongly urged her to contact our Firm for some guidance. That is when we got involved.
We sought and obtained Cigna's claim file, which was never sent to Ms. W. At first, Cigna sent a partial claim file, leaving out significant information. We pressed Cigna and received a full copy of the file, which contained all of Cigna's internal emails, notes, medical reviews, and surveillance videos and reports. Our Firm discovered several glaring issues with Cigna's claim review process. First, for several years, Cigna never requested updated medical records. It only requested that Ms. W. and her physicians provide a yearly statement. Assuming that was all that was required, that is all Ms. W. submitted. However, Cigna used this against her, asserting that there was not objective evidence or sufficient proof to support her continued claim of disability. Next, Cigna appeared to be trying to find any reason to deny Ms. W.'s claim. Over the years, they placed Ms. W. under surveillance multiple times. Most of the time, Cigna saw little to no activity on the part of Ms. W. and the little activity actually seen on video involved various doctor's appointments, trips to the pharmacy, and the occasional trip to the store, all showing Ms. W. walking slowly, appearing in pain, or with the assistance of a cart. Cigna entirely ignored the surveillance, which clearly supported our client's continued disability. Further, Cigna had a medical reviewer evaluate Ms. W.'s file. An investigation into the reviewer revealed that he had little to no experience in treating fibromyalgia. Originally, his report appeared to support Ms. W.'s limitations However, after pressure from Cigna for continued "clarification," the reviewer added 2 separate addendums to the report, each time altering his conclusions until it could be read to support that Ms. W. was no longer disabled. Finally, Cigna entirely dismissed Ms. W.'s SSDI award and the Social Security Administration's (a truly independent entity) determination that Ms. W. was unable to maintain gainful employment in any occupation. Cigna's refusal to consider this compelling evidence was most troubling considering it required that Ms. W. apply for the benefits and reduced her monthly Cigna payments by the amount of her SSDI benefits. Such actions are entirely inappropriate under the law.
Our Firm obtained all of Ms. W.'s records, interviewed her physicians, and obtained sworn medical narrative statements from her physicians, which also addressed the inaccuracies in Cigna's claim review report. We then sent Ms. W. to an independent medical examiner, who prepared a detailed report supporting Ms. W. continued disability. With this, we submitted a comprehensive appeal, which detailed Ms. W.'s debilitating symptoms and outlining the bias nature of Cigna's review process. Cigna overturned its claim decision and our client is receiving her monthly benefits to date. Fortunately, we were able to overturn Cigna's decision in time to save our client from losing her home.