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CIGNA Long Term Disability Denial of Benefits for Traumatic Brain Injury, Mental/Nervous Disorder and Physical Conditions Overturned on Appeal

| May 7, 2019 | Disability Insurance Law Blog |

Ms. Doe hired DI Law Group to assist her in the claims process after being confused by CIGNA’s handling of her claim due to Traumatic Brain Injury. Ms. Doe suffers from Mental/Nervous Disorders including anxiety and depression as well as physical conditions, and Traumatic Brain Injury that affect her functionality and have prevented her from performing any or all of the material and substantial duties of her regular occupation as a Senior IT Business Analyst.

Ms. Doe had two (2) accidents where she fell and hit her head and suffered a concussion and back injury. Despite her injuries, she returned to work, but it became apparent that she was unable to function at her prior capacity. Ultimately, Ms. Doe was reassigned to a different department, but remained unable to keep up with the job and perform the job with any reasonable continuity. Thus, Ms. Doe applied for disability with her Employer and was initially approved for a short time her benefits were inexplicably terminated. DI Law Group successfully appealed the denial and Ms. Doe was awarded the remainder of her short-term disability benefits.

Ms. Doe also applied for long-term disability benefits and was denied outright. DI Law Group submitted a timely appeal providing substantial proof of her disability. Cigna hired “independent medical reviewers” who questioned the legitimate, reliable and supportive findings from the testing without any contrary proof. In response, DI Law Group sent Ms. Doe to another Neuropsychologist in order to conduct additional, non-duplicative testing to satisfy Cigna’s questions.

As a part of the Appeal, DI Law Group outlined how Cigna sent conflicting correspondences to Ms. Doe prior to DI Law Group‘s involvement and failed to clarify her rights or the appeals process. We also addressed Cigna’s mistaken belief that the short-term disability appeal was intended to also be an appeal of the long-term disability denial. Apparently, Cigna was attempting to foreclose Ms. Doe’s right to appeal a denial of benefits which would have devastating effects on her ability to later collect such benefits!

Another issue addressed by DI Law Group in the long-term disability appeal was the fact that Cigna’s hired third party vendor, NMR, who unilaterally scheduled an Independent Medical Evaluation (“IME”) of Ms. Doe and then attempted to claim that she failed to cooperate in attending such evaluation. However, DI Law Group communicated with Cigna and NMR regarding the unilateral scheduling of the IME in order to come to a mutually agreeable time and date and also to obtain an understanding of the type of IME and test that were to be covered, as well as to demand that a witness be present for any such testing. Cigna responded by advising that the testing was neuropsychological testing. Thus, DI Law Group explained that Ms. Doe already underwent neuropsychological testing and given the Test Rest Effect, that the same tests could not be administered. DI Law Group provided Cigna with research on the Test Retest Effect. Thereafter, Cigna did not pursue additional testing.

Additionally, Ms. Doe’s appeal included detailed responses from one of the neuropsychologists to all of Cigna’s initial questions, regarding such physician’s findings. Cigna attempted to discredit the neuropsychologists findings and opinions without any support for its arguments, which DI Law Group specifically addressed. DI Law Group also addressed Cigna’s baseless questioning of the reliability of an established and credible licensed psychologist, without providing any basis/support for its contention. DI Law Group pointed out that the treating physicians and recent neuropsychologist clearly found the initial neuropsychological evaluation and findings reliable, yet Cigna, without any basis, concluded otherwise!

Finally, as a part of Ms. Doe’s appeal, DI Law Group addressed that Cigna failed to meet the requirements for procedures and notification when an administrator denies a claim for benefits. Specifically, ERISA requires that specific reasons for denial be communicated to the claimant and that the claimant be afforded an opportunity for ‘full and fair review’ by the administrator.

Upon receipt and review of the Appeal submitted by DI Law Group, Cigna overturned the denial and awarded Ms. Doe Long-Term Disability benefits, which she continues to receive today.

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