Here, Chernequa Dawson (“Dawson”) worked as a Care Transition Coordination (“CTC”) Nurse Care Manager and was employed by Cigna Corporation (“Cigna”). Through her employment with Cigna, she was covered under both a short-term and long-term disability plan. For these plans, Cigna pays the short-term disability plan benefits, while Life Insurance Company of North America (“LINA”) pays for long-term disability benefits. LINA is also the entity responsible for determining both benefits and eligibility for the plans.
The short-term disability plan states:
“You have a covered disability . . . if, because of a medical condition related to an accident, illness or pregnancy:
- You are unable to perform the essential functions of your current or a similar role for at least six consecutive scheduled work days;
- The essential duties that you cannot perform cannot be reassigned to another person in order to accommodate your return to work;
- You cannot, based on your lack of work experience or on work restrictions related to your medical condition, be reassigned to another position within 15% of the market value of your current role; and
- Your physician provides objective medical evidence to support his or her assessment of your medical condition.”
Further, the long-term disability plan states “The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is unable to perform all the material duties of his or her Regular Occupation or a Qualified Alternative.” In determining whether an employee is able to work, there are several factors: 1. The medical evidence provided by the employee; 2. Consultation with the employee’s medical providers; 3. Not more than three independent reviews by experts; and 4. An employment offer from the employer which meets the employee’s ability to work. An “Elimination Period” must also be passed before an employee can receive any benefits.
Dawson was injured on July 10, 2014, because an electric wheelchair ran over her feet and pinned her against a wall. Following this, she had approximately fifty doctor visits with twelve medical providers in one year. She filed for short-term benefits soon after and was granted those benefits from July 11 to September 6, 2014. On October 8, LINA denied her claim for benefits because the “medical information on file did not provide evidence of a functional impairment restricting you from performing every day job duties.”
The letter continued to state that a Dr. Kiva Davis’ notes showed that Dawson’s July 21 examination “was mostly within normal limits, mild, [sic] limitation in your hips” and that Dawson was “voluntarily restricted . . . the range of motion in your knee was at 90 degrees, your reflexes were equal, there were no bruises, skin discoloration, or swelling.” A Medical Director’s review of Dawson’s file had indicated that “the provider’s restrictions are not supported by any acceptable clinical or laboratory findings. The diagnostics were inconsistent with other substantial evidence in your claim file.” In conclusion, the letter from LINA stated that “We acknowledge that you may have been experiencing symptoms related to your lower leg injury. However, the medical information received does not support how you are unable to perform your light occupation as a Nurse Case Manager beyond September 6, 2014.”
At this point, Dawson appealed the decision. However, on January 21, 2015, LINA again chose to affirm its denial. It submitted that evaluations with Dr. Davis could not be completed due to Dawson’s pain. Similarly, an orthopedic evaluation with Dr. Kenneth Berliner was unable to be completed and evaluation with Dr. Kevin Prentice also found that the examination was limited due to Dawson’s pain. In conclusion, LINA stated that “There was no clinical evidence that would demonstrate a functional loss and inability to perform your occupation beyond September 6, 2014.”
Dawson again chose to appeal, which LINA denied on June 10, 2015. Dawson submitted additional information, including records from visits with Drs. Grover and Peer, respectively. The denial letter provided by LINA explained that “there are no documented measured loss [sic] of ability to perform the duties of you [sic] job. Please understand that we are not stating that your conditions did not exist, but that the objective clinical evidence on file is not supportive of functional impairment to the degree that you would have been unable to work.”
By July 24, 2015, LINA had denied Dawson’s long-term disability benefits claim. Citing a peer review of her medical records, LINA stated that there was “no evidence of any injury sustained on July 10, 2014, other than contusions to the lower legs and ankles.” After additional review by a number of parties, it was “recommended that the medical records provided by your Health Care Professionals lack quantifiable, objective clinical exam findings, testing, or imaging that show a physical or psychiatric functional impairment that would preclude you from working in your own light occupation through the Elimination Period. . . .”
Dawson then appealed the denial of her long-term disability benefits, which LINA subsequently affirmed. The letter again cited a lack of support for Dawson’s work restrictions. This led to Dawson filing the instant lawsuit on August 15, 2016. Her main allegation is that both her short-term and long-term disability benefits were wrongfully terminated. LINA also filed a counter-claim, alleging that it is due benefits that were overpaid to Dawson.
The court believed that LINA was not arbitrary and capricious in its denial of Dawson’s benefits. It cited that even though Dawson had pain and physical symptoms after her accident and injury, she did not provide enough objective medical evidence to indicate functional losses or her inability to perform her duties. The court felt that because Dawson’s short-term benefits were properly denied, that she is not entitled to payment of any long-term disability benefits.
In addition, the court granted a motion in favor of LINA because Dawson did not contest the fact that she was in receipt of workers’ compensation payments of $637.50. Overall, the suit resulted in a ruling in favor of LINA and against Dawson.[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.]
Here is a copy of the decision in PDF: