Rodriguez v. Cigna / LINA – A Win for the Claimant

Alba Rodriguez v. Life Insurance Company of North America

In this case, Alba Rodriguez (“Rodriguez”) was an employee of Henry Ford Health Service and held the title of Associate Director of the Center for Integrative Wellness. Her job was considered to be that of a Program Manager, with duties such as leading large group wellness programs, traveling to various conferences and other offices, creating and implementing operations relating to group wellness programs, supervising and training staff and program leaders, drafting publications, and serving on committees both internally and externally.

In 1986, Rodriguez was in a car accident wherein she experienced fractures to her pelvis, left hip, spine, and left acetabulum. She underwent reconstructive surgery for her pelvis, and had hardware implants done. A year later, she had a total left hip arthroplasty. In 2004, Rodriguez was diagnosed with a cervical herniation. Much later, Rodriguez slipped and fell on January 28, 2012, reinjuring her back and left hip as a result of the fall.

Rodriguez was a participant under a long-term disability (LTD) benefits plan, administered by Life Insurance Company of North America (“LINA”) – which is also known as Cigna. Under the plan, there must be “satisfactory proof of Disability before benefits will be paid” and there must be “continued proof of the Employee’s Disability for benefits to continue.” A claimant also had to prove that she was disabled through a 180-day elimination period. The plan further defines “Disability/Disabled” as the following:

               “The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:

  1. Unable to perform the material duties of his or her Regular Occupation; and
  2. Unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation

              After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is:

  1. Unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and
  2. Unable to earn 60% or more of his or her Indexed Earnings.”

Five months after the accident, Rodriguez underwent a revision surgery of her arthroplasty. Her orthopedic surgeon, Dr. Robb Weir, indicated that she should be able to return to work unrestricted on September 10, 2012. Eventually, Dr. Weir noted that Rodriguez was experiencing some back pain issues, which resulted in a delayed work release date of December 10, 2012.

On November 30, 2012, LINA informed Rodriguez that she had not sufficiently proved that she was disabled throughout the 180-day elimination period. Rodriguez submitted additional information from Dr. Shlomo Mandel, who treated her back pain, and Dr. Weir. A Claim Manager and Nurse Claim Manager reviewed Rodriguez’s file and reached out to the doctors. Dr. Weir indicated that Rodriguez would be able to return to work on January 2, 2013. Further, Dr. Mandel’s office stated that Rodriguez was capable of executing sedentary work, if she was allowed to sit and make position changes as she needed.

Subsequently, LINA denied Rodriguez’s claim again on December 28, 2012. It stated that her doctors did not provide any information that would keep her from performing her own occupation. Rodriguez appealed on June 27, 2013, and submitted additional information from her doctors. A Dr. Ramon Nunez did not indicate any specific restrictions, but also did not indicate any examination dates. However, a Dr. Steven Fried stated that Rodriguez’s restrictions would likely keep her from working her own occupation. Following this additional information, an Appeals Specialist reviewed Rodriguez’s file. Dr. Nick Ghaphery found that there was nothing in her medical records to keep her from performing her job duties in a sedentary manner.

LINA again denied benefits on October 29, 2013. Rodriguez followed up with information from doctors’ visits and a Physical Medical Questionnaire from Dr. Nuala Crotty. The questionnaire explained that Rodriguez’s pain could interfere with her ability to concentrate, pay attention, and perform. LINA informed Rodriguez that Dr. Crotty did not provide any limitations that showed she was unable to do sedentary work. Rodriguez asked that LINA reconsider and later submitted a favorable decision from the SSA and more medical records from a Dr. Simon Faynzilberg.

LINA then sent the file to Dr. Sloane R. Blair for review. He determined that Rodriguez was limited from June 18, 2012, to May 15, 2015. More specifically, he noted certain work restrictions such as changing positions and carrying limited amounts. A Vocational Specialist also reviewed Rodriguez’s file, noting that Dr. Blair’s restrictions “are consistent with the required physical demands of her occupation as Program Manager, […] Sedentary, at this time.” LINA therefore upheld its denial on June 4, 2015, whereafter Rodriguez filed this suit.

The court held that Rodriguez properly submitted proof of her disability as required during the 180-day period. In support of this holding, the court cited that LINA never addressed the issue that Rodriguez’s pain could affect her ability to perform significant cognitive abilities. Instead, it focused primarily on her physical ability to perform. Several of Rodriguez’s treating physicians indicated chronic pain and/or an inability to concentrate or perform work. The court also felt that their decisions were well-documented. Further, the court held that the SSA determination submitted by Rodriguez was persuasive. More particularly, Rodriguez’s pain was documented consistently over a number of years and her physical impairments were objectively identifiable.

As a result of the above, the court held that LINA failed to make the required showing that Rodriguez could return to work. Therefore, the court held that Rodriguez was entitled to LTD benefits for the “own occupation” period. The court subsequently ordered LINA to pay Rodriguez benefits from December 24, 2012, to December 24, 2014, in addition to costs, interests, and attorneys’ fees.

Additionally, Rodriguez sought a determination that she was entitled to benefits during the “any occupation” period. However, because there was no administrative evaluation of the “any occupation” eligibility in the record, the court felt it was appropriate to remand that particular matter.

[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.] Rodriguez_v_LINA-USCOURTS-2_15-cv-12768-0 (ED MI)

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