In 2003, Susan Kristoff was diagnosed with breast cancer. After undergoing treatment, it was determined that she was in full remission and cancer free. As a precautionary measure, she was placed on Tamoxifen to prevent the recurrence of cancer in the future. Later, Susan was hired as an outside salesperson for a large corporation and obtained a disability insurance policy with Cigna through her employment. Susan continued to undergo regular evaluations and each time, her physicians assured her she remained cancer free.
As time went on, Susan began to experience severe a debilitating pain in her hip and she started to feel run down. After remaining cancer free for three years, Susan was ultimately diagnosed with metastatic cancer, which caused two large holes in her hip. She was devastated by the diagnosis and eventually she was unable to continue to work. At first, Cigna denied her claim for Short-Term disability benefits, unreasonably asserting that there was no evidence that she could not continue to work as an outside salesperson while undergoing treatment for her metastatic cancer. This is when Susan hired our Firm. We filed an administrative appeal of Cigna’s Short-Term disability denial and applied for Long-Term disability benefits. Cigna eventually overturned its decision and paid Susan Short-Term disability benefits. However, Cigna denied Susan Long-Term disability benefits, this time asserting that while Susan was unable to work, her cancer was a pre-existing condition and she was ineligible for benefits. Cigna’s position was that since Susan was taking Tamoxifen prior to the effective date of her policy, she was receiving treatment for cancer.
We submitted an administrative appeal of Cigna’s Long-Term disability denial and pointed out that Cigna’s newest position was again, entirely unreasonable and inappropriate under the terms of her plan. First, her disability plan provided that a condition is considered pre-existing only if during the 3 months prior to the effective date of her policy, Susan was diagnosed with or treated FOR the disabling condition. Susan was not diagnosed with cancer in the 3 months prior to the effective date of her policy. Susan’s scans specifically established that Susan did not suffer from cancer in that three month period. She was continuously determined to be cancer free. Moreover, Susan was not taking Tamoxifen as a treatment FOR cancer. She did not have cancer. This was simply a precautionary measure to prevent cancer from developing in the future. Eventually, Cigna agreed and overturned its unreasonable denial. Susan’s case was featured on Good Morning America, which shined a light on Cigna’s bad faith claims practices and unconscionable behavior. It was explained in the Good Morning America segment that Cigna appeared to be engaging in a well-known insurance tactic called “slow walking,” in which claims are denied or decisions delayed, in the hopes that claimants will either give up in frustration or be too sick to continue the fight. However, Cigna alleged that it simply made a mistake and with additional information, it was ultimately able to rectify the error in Susan’s case. However, there was no new information presented.
Over the years, our Firm has received numerous complaints from other Cigna disability insurance beneficiaries who were denied benefits by Cigna under almost identical facts. In many of these cases, the same exact precautionary medication was taken, while the claimants were demonstratively cancer-free at the time that their policies became effective. Each time, we established that the claimants were wrongfully denied as their conditions were simply not pre-existing under the terms of their disability policies. Importantly, in those cases we were able to point out to Cigna that it came to a contrary claim determination in numerous cases in the past (including Susan’s case). While Cigna overturned those claim decisions when faced with this information, it has continued to engage in a pattern and practice of slow walking. We continue to receive calls from claimants and other law firms reaching out to us for help because they heard about Susan’s case and find themselves or their clients in a similar situation with Cigna. Most of these cases, like Susan’s, fall under the Employee Retirement Income Security Act of 1974 (“ERISA”), as the claimants obtained their policies through their employment. Under ERISA ‘s Regulations, administrators like Cigna are required to treat similarly situated claimants comparably. Thus, knowingly denying a claim as pre-existing when it previously determined that a condition was not pre-existing under almost identical facts, with almost identical policy terms, is a violation of Cigna’s obligations under the law. Indeed, it is the epitome of arbitrary and capricious decision making.