Long Term Disability Reconsideration (Informal Review Process)

Cigna (New York Life) Long Term Disability Reconsideration Win (Informal Review Process): Proving Physical Disability from any Gainful Occupation due to Chronic Pain and Swelling following Multiple Orthopedic Surgeries

A female client in her early 60’s had her long term disability benefits terminated by New York Life insurance company (doing business as Cigna) as of the date her long term disability insurance policy transitioned its definition of “Disability” from the individual’s ability to perform her regular occupation to any gainful occupation. Our client had a long history of multiple knee replacements with complications, neck surgery, and hip replacement. After paying 24 months of LTD benefits, the insurance carrier alleged that the claimant was physically capable of performing a full-time sedentary occupation.

Our client handled her own appeal, which was denied by the insurance company based on the opinion of a non-examining orthopedic surgeon who alleged that our client had no functional limitations. Our client came to us after she exhausted her appeal rights. Often the only recourse is then litigation, which in this case would have involved filing a lawsuit in federal court under the Employee Retirement Income Security Act of 1974 (ERISA).

Based on our review of the insurance company’s long term disability claim file, it became apparent that the insurance company was missing treatment records during its prior reviews of the claim.

Our law firm was retained and, in an attempt to avoid a lawsuit, we submitted additional documentation to New York Life (Cigna). New York Life refused our request for a formal voluntary appeal review, but did agree to reconsider the additional evidence that we submitted on our client’s behalf via an informal “reconsideration” review process. However, it is important to note that once an individual’s appeal rights are exhausted, an insurance company may not agree to conduct any further review even if the circumstances may provide good cause for such a review to occur – for example, the person was unrepresented, new and material evidence is available, procedural or factual errors were made by the insurance company, etc… For this reason, it is always best to consult with an experienced long term disability attorney as soon as a LTD claim is disputed or limited and prior to the submission of an appeal request.

The additional evidence submitted to New York Life (Cigna) included medical records with severely abnormal clinical examination findings, comprehensive medical charts, an independent medical examination report, and vocational evidence. We argued that our client is incapable of any form of employment, including sedentary work (a desk job), due to the severity of her physical medical impairments. We also presented vocational arguments seeking to disprove the existence of Surveillance-System Monitor positions and explaining why our client could not perform the physical demands of the only other alternative occupation that the insurance company alleged our client could qualify for based on her education, training, and experience.

Despite the lack of a formal review process that would afford our client “review and respond” rights, the insurance company’s reconsideration of the additional medical and vocational evidence proved successful. The award of our client’s LTD benefits following the final denial of her claim is a unique result that certainly represented a best possible outcome for our client. Past-due long term disability benefits were paid with monthly benefits being reinstated and payable into the future.

Our law firm highly recommends that any disabled claimant facing a denial of termination of benefits retains an experienced disability insurance lawyer for representation during the administrative appeal process and not after that appeal review process has proved unsuccessful. Our law firm’s legal consultations are free. Contact us at (267) 419-7888.