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SMDA recently convinced Cigna to overturn a claims denial decision by filing a comprehensive administrative appeal of the LTD claims denial decision.

SMDA was hired by a client who worked for Norwegian Cruise Lines who developed significant back problems. His back problems became so severe that he was put off the ship by the ship’s doctor and shortly thereafter underwent back surgery. He did his best to return to work but continued to experience significant problems. The ship’s doctor again discharged him from the ship.

Despite this information, CIgna originally denied his claim for LTD insurance benefits. SMDA convinced Cigna to reverse its denial decision after obtaining, reviewing and analyzing the voluminous medical records and explaining why he continued to satisfy the insurance policy’s definition of disability.

In a case mentioned previously on this Blog, a Long Term Disability Insurer (MetLife) reversed its claims denial decision upon remand from Federal Court.

The client last worked in 2009 and can expect more than five years of past due benefits. This is an unusual circumstance for a case with a long and twisting procedural history.

The client originally came to SMDA while represented by another law firm while she was facing a motion to dismiss her case based on the statute of limitations. SMDA agreed to take her case and won the motion to dismiss-convincing the Court that the language of MetLife’s LTD insurance policy was ambiguous in explaining when she had to file suit to preserve her claim.

The US Supreme Court heard oral arguments yesterday in the Heimeshoff v Hartford Life case. The question considered by the Court was when does the statute of limitations start to run? Ms. Heimeshoff (and the Department of Labor who filed an amicus brief) argued that the limitations period should not commence until after her LTD claim was denied because she could not bring suit until she had exhausted her administrative remedies.

This case presents an interesting issue of whether an insurance company has the contractual right to require the statute of limitations to start running well before a claimant has the ability to bring a lawsuit. It would seem that issues of fundamental fairness would dictate that a limitations period cannot start to run before a claimant has the ability to seek court review.
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HartfordBusiness.com is reporting that LTD Insurer Cigna has agreed to pay $77 million dollars to settle claims brought by regulators in four states for improperly handling long term disability claims.

While it is not clear what initiated this particular dispute, it has been this firm’s experience that we see more complaints about Cigna LTD claims and cases than any other LTD carrier. In fact, we see more Cigna cases than most of the other LTD insurer’s combined. Cigna is my most “frequent flier.” I am not sure of that is because Cigna has the largest market share or if it is a result of its claims handling decisions. It would seem this regulatory settlement might favor the latter explanation. This reminds me of the Unum regulatory settlement almost 10 years ago. It will be interesting to follow this story as more details emerge.

If you have a Cigna claim that has been denied give us a call for a free consultation.
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I came across this recent article by the Onion satirizing Long Term Disability insurer giant, Cigna. WARNING-STRONG LANGUAGE, NOT APPROPRIATE FOR ALL. The article takes a satirical poke at CIGNA for failing to treat its insureds fairly. While the article is obviously based upon the Onion’s imagination it will likely strike a chord with anyone who has been put through the arduous LTD claims process or had their claim denied from some apparently bogus reason.

I have to say that I get more calls about CIGNA denials than almost all the other LTD insurance companies combined. I also have personally represented a number of clients where the claims denial rationale leaves me scratching my head. Bad claims decisions make good cases. Unfortunately, the client/insured is the one who pays the price while struggling to make ends meet until the claims denial can be reversed.

Our client went off work due to the progression of her Meniere’s disease.

She went back to work part-time and struggled to work five-hour days. She was scheduled to return to work full-time in November but was unable to do so due to her medical condition. She did gradually increase her hours but was never able to return to full-time work. She became completely unable to work the following March due to her Meniere’s disease and migraines.

When the LTD insurance company denied her appeal SMDA filed suit. During a court ordered facilitation a confidential settlement was reached.
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Long Term Disability Insurers love to use surveillance to find a way to terminate benefits. Think about it it from a business perspective. They can hire a private investigator and pay them $500 or a $1000 dollars to follow a claimant around for a few days and maybe save tens or hundreds of thousands of dollars if they can just get something on tape that they can use to terminate the claim. This is the story of one such claim.

SMDA was hired by Mr. S who last worked as a senior programmer for EDS when his significant and progressive back problems stopped him from working. He had been diagnosed with lumbar post laminectomy syndrome with lumbar radiculopathy, lumbar spondylosis with low back pain and lower extremity pain. As a result, he had severe low back pain with aching, shooting, sharp, and throbbing pain with numbness, tingling, burning and stiffness on a daily basis. Objective testing including multiple MRI’s and EMGs have confirmed his significant deficits. The LTD Insurer originally approved his claim and paid his LTD benefits for years.

Despite the overwhelming medical evidence demonstrating his progressive disability, the LTD Insurer hired a private investigator to follow Mr. S around. During the first several days the private investigator saw nothing but the outside of the client’s house. The last day, Ms. S left the house and went to Walmart. The videotape shows Mr. S slowly getting out of his car and walking into the store leaning heavily on both his cane and then the grocery cart. The private investigator followed him into Walmart and up and down several aisles as he surreptitiously videotaped Mr. S. The video shows Mr. S picking up and looking at several items each of which weigh less than 2 pounds, leaning on his shopping cart and going through the check-out.
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Four Michigan Supreme Court Justices (Young, Markman, Kelly and Zahra) issued a decision changing 30 years of No-Fault Insurance law finding that automobile insurance companies no longer need pay No-Fault benefits to a person who is injured while closing their car door.

In Frasier v Allstate, the claimant, Mona Lisa Frasier had put some personal belongings in the passenger side of her car and was in the process of closing her car door when she fell on some ice and was injured. Mona Lisa made a claim with her car insurance company, Allstate to get her medical bills paid. Why? because the the Michigan No-Fault statute says the car insurer has to pay for your medical care if you are hurt as “a direct result of physical contact with equipment permanently mounted on the vehicle[,]” or if the injury occurs “while occupying, entering into, or alighting from the vehicle.”
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Our client last worked as a RN at a local hospital when she developed significant orthopedic problems following hip replacement surgery. She filed a claim for LTD benefits with the insurance company who provided group disability insurance through her employer, Oakwood Hospital. The insurer paid her disability claim for the first 24 months and then terminated her benefits claiming she was capable of working in a sedentary capacity.

After the insurer denied the administrative appeal filed by the firm, SMDA filed suit to compel the disability insurer to reinstate her LTD benefits. On the eve of the date the Court was to consider the party’s briefs the insurance company threw in the towel and voluntarily agreed to reinstate the client’s LTD benefits and pay the attorney fees incurred. This result is a clear lesson that it is critical that the administrative appeal be handled correctly as the administrative record in this case was overwhelmingly favorable to the client. The insurance company realized there was little chance of convincing the Court that it was correct in terminating her benefits.

It has been quite awhile since I last posted a blog. I have not had the time to post because while I was away I tried several cases.

In addition to handling Long Term Disability cases our firm also handles various other types of matters including automobile accident insurance claims.

In December I tried a case for a client who was injured in a 2005 motor vehicle crash. She had neck surgery for a herniated disc but continued to have pain and problems for which she received ongoing treatment. Her Insurance company, which I will not identify, (State Farm) refused to pay for any of her medical care. When a person is injured in a car crash their insurer is responsible for paying their personal injury protection (PIP) benefits, including lifetime medical care.

My client is the nicest person who takes care of an adult child with profound disabilities. The Insurance company did everything it could to try and avoid paying her medical bills going so far as to argue that she could perform physical therapy on herself at home.

I am glad to say that the jury completely rejected the Insurance Companies arguments and decided they should pay every single penny that we sought.
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