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The 5th Circuit Court of appeals recently reversed a ruling for a worker suffering from Reynaud’s Disease, which is a condition preventing the claimant from working in a cold environment.  Unfortunately, the claimant worked at a chicken processing plant as a Hazard Analysis coordinator.  Her job duties required  that she inspect each part of the processing plant, including the refrigerated sections where the temperature was maintained at approximately 40 degrees.  The LTD insurance policy provided benefits if she was disabled from  “performing the duties of her Regular Occupation.”  Reliance Standard, the Long Term Disability Insurer, denied the claim based upon an in-house vocational reviewer who concluded her regular occupation would be classified as a “Sanitarium” as defined by the DOT and that the material duties “include neither employment at a poultry processing plant nor exposure to the cold.”   Utilizing an abuse of discretion standard the Appellate court overturned the lower court’s decision for the claimant.

This is just one more in a very long line of cases demonstrating the difficulty claimant’s face in pursuing ERISA claims for Long Term Disability Insurance benefits.  And, in my opinion, the inherent unfairness in the current state of the law.

SMDA recently obtained a reversal of CIGNA’s decision denying Long Term disability Insurance Benefits to a Henry Ford Hospital employee.  As a result of our comprehensive administrative appeal CIGNA (aka Life insurance Company of North America) overturned its decision denying our client’s claim for benefits.  Our client suffered from a number of conditions including Type 2 Diabetes Mellitus, Neuropathy, Asthma, COPD, Arthritis, and carpal tunnel syndrome. We convinced CIGNA to reinstate the disability insurance benefits even under the more stringent “any Occupation” definition of disability.

SMDA recently convinced  LTD insurer Cigna to overturn its claims denial decision for a registered nurse who developed significant low back pain that prevented her from performing her own occupation.  Our client had degenerative disc disease that had progressed over the years eventually leaving her unable to work.  Cigna initially denied her claim finding she was not disabled.

SMDA filed a comprehensive administrative appeal which established that the functional limitations the client experienced made it impossible for her to perform the material duties of her own occupation.  Cigna overturned the claims denial decision and agreed to retroactively reinstate her LTD benefits and put her back on claim.

A US District Court Judge recently granted a motion filed by SMDA granting LTD benefits to one of our clients.  The Court found that the third party administrator had abused its discretion in recommending a denial of benefits.  The Court found that the client’s serious back problems along with the multiple powerful pain medications prevented him from performing the duties of his own occupation.

SMDA partner, Patrick Derkacz, recently recovered $1.2 million dollars on behalf of his seriously injured clients.  Mr. Derkacz convinced State Farm to pay this significant settlement the day after taking the deposition of the at-fault driver who offered testimony  that he was not responsible for causing this rear end accident.  The at-fault driver tried to blame everyone but himself, including the seriously injured driver of the car he struck for not traveling the minimum speed on the freeway.  (The  freeway traffic was slowing to a stop for a previous accident!)  State Farm likely realized that any potential jury would not look kindly upon Defendant’s ridiculous testimony.

This significant recovery should help the elderly couple injured in the crash the economic cushion they need to live their lives as they wish.

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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