In this case, the U.S. District Court for the Northern District of California ruled in favor of Plaintiff Sarabjit Sangha and ruled against Cigna Life Insurance Company of New York. Specifically, the Plaintiff appealed Cigna’s denial of her long-term disability (“LTD”) benefits. After reviewing briefs submitted by both parties, the Judge overturned Cigna’s denial of LTD benefits.
Plaintiff’s Background: Since August 2010, Sangha worked as a Buyer/Subcontractor Administrator for Loral Space & Communications Inc.
Plaintiff’s Disabilities: Sangha suffered from chronic pain secondary to cervical degenerative disc disease and C4 to C7 spinal fusion surgery, failed neck surgery syndrome, right cervical radiculitis, lumbar disc protrusion with facet hypertrophy at L4-L5, L5-S1, right lumbar radiculitis and sciatica, probable opioid dependency, chronic myofascial pain syndrome, and displacement of cervical intervertebral disc without myelopathy.
Definition of Disability: As I constantly reiterate, a long term disability claim is a claim based on a contract. Thus, it is critical to review the contract to determine the rights and responsibilities of a claimant under that contract.
Under the terms of this Cigna contract, an employee is considered “disabled” under the Policy if:
[B]ecause of Injury or Sickness,
1. he or she is unable to perform the material duties of his or her regular occupation, and solely due to Injury or Sickness, he or she is unable to earn more than 80% of his or her Indexed Covered Earnings; and
2. after Disability Benefits have been payable for 24 months, he or she is unable to perform the material duties of any occupation for which he or she may reasonably become qualified based on education, training or experience, and solely due to Injury or Sickness, he or she is unable to earn more than 60% of his or her Indexed Covered Earnings.
Procedural History and Individuals Used By Cigna to Try and Deny Claim: Under this definition, Cigna initially approved benefits from November 19, 2011, to October 29, 2012.
Cigna had the claim reviewed by:
- Nurse Case Manager Nancy Lescher and
- Associate Medical Director Dr. Penny Chong, M.D., Board Certified in Internal Medicine.
Predictably, both of these reviewers found that Plaintiff’s limitations and restrictions were not supported and Cigna denied the claim for benefits beyond October 29, 2012.
Plaintiff appealed, submitting additional information in support of the claim.
Cigna had the claim reviewed by more “independent” providers:
- MES Solutions, a third-party vendor;
- Dr. Mark D. Watson, M.D. Board Certified in Physical Medicine and Rehabilitation; and
- Melissa Mendez, a Rehabilitation Specialist.
Surprisingly, Ms. Mendez found that the restrictions and limitations provided by Dr. Watson were not consistent with the physical demands of Plaintiff’s occupation and Cigna overturned its previous denial of Plaintiff’s disability benefits.
Defendant paid Plaintiff LTD benefits for a few more months. During this time, Plaintiff continued her treatment and Defendant continued its review of Plaintiff’s claim. In November 2013, Plaintiff underwent substantial testing with a physical medicine and rehabilitation specialist, Dr. Tulsidas Gwalani. On December 30, 2013, she underwent a psychological evaluation by Robert Avenson.
Cigna also had Ms. JoAnn Orozco, a Nurse Case Manager, review Plaintiff’s updated records. Again, not surprisingly, Ms. Orozco found that there was an “[o]verall lack of significant physical exam findings to support a functional loss.” Dr. Chong came back into the picture again and he concluded that “[o]ngoing functional loss was not demonstrated.” By her own admission, Dr. Chong found “no time-concurrent exam notes available for review,” and that medication side effects “were not reported or observed.”
Sangha initiated another appeal in April 2014 and submitted updated medical records from her physical medicine and rehabilitation specialist. Dr. Mahawar referred Plaintiff for cervical and lumbar epidural injections, and, due to Plaintiff’s pain, Dr. Mahawar “recommended restrictions of no sitting for more than 1 hour without a break of 15 minutes, no repetitive use of her hands and fingers, and no lifting more than 5 pounds occasionally.” Dr. Mahawar also completed a “Physical Ability Assessment” (“PAA”), wherein Dr. Mahawar specified Plaintiff’s durational capacity for certain activities in an 8-hour workday. Dr. Mahawar opined that Plaintiff could stand, walk, reach, lift, carry, push or pull an object only “occasionally,” that is, for 0 to 2.5 hours per day. Dr. Mahawar found that Plaintiff could return to “sedentary work only” on July 15, 2014, with specific restrictions including no lifting more than 10 pounds occasionally, and minimal twisting.
To review Plaintiff’s records, including Dr. Mahawar’s findings, CIGNA retained Dr. Charles Brock, M.D. Dr. Brock evaluated Plaintiff’s treatment records. Based on this medical documentation, Dr. Brock concluded:
“The available medical records for the time period 03/17/14 forward indicates persistent pain and would support restrictions/limitations with a loss of range of motion associated with the surgery. Mrs. Sangha otherwise does not demonstrate any focal neurologic disturbance in regards to motor, sensory, reflex or cranial nerve evaluation. Due to the reported multilevel fusion, Mrs. Sangha would be restricted from any extremes of right or left cervical side bending or rotation of the cervical spine. Mrs. Sangha would be recommended to not lift, push, pull or carry anything over 10 pounds on an occasional basis due to the noted cervical surgery multilevel and the effect on structural integrity from a multilevel fusion. Mrs. Sangha otherwise is able to grasp, grip and manipulate as needed. The available medical records otherwise would support the ability to occasionally bend, stoop, crouch or crawl the ability to sit and occasionally stand or walk in my medical opinion.”
CIGNA overturned its prior denial of Plaintiff’s LTD benefits under the “any occupation” standard based in part on Dr. Brock’s review.
Following the reinstatement of Plaintiff’s LTD benefits, Plaintiff continued her pain management treatment plan, including epidural steroid injections, trigger point injections, and pain medications prescribed by Dr. Mahawar. Plaintiff’s chief complaints during this period were chronic neck pain, lower back pain, and pain in her right shoulder and arms.
On January 24, 2016, Defendant again reviewed Plaintiff’s LTD benefit eligibility. Plaintiff submitted her medical records, and underwent a Functional Capacity Evaluation (“FCE”) arranged by Cigna. The FCE was performed by Jonathan Blue, DPT, on May 12, 0216. Mr. Blue found that Plaintiff “was limited in her ability to tolerate maintaining static positions for prolonged periods of time throughout the test.”
Based on the limitations and restrictions set forth in the Blue FCE, Randy Norris, MS, CRC, CCM, conducted a Transferable Skills Assessment (“TSA”) dated May 17, 2016. Mr. Norris found two occupations in the Fremont, California labor market that purportedly satisfied Plaintiff’s restrictions and the Policy’s wage requirement: (1) Financial-Aid Counselor, and (2) Procurement Engineer. Following the Blue FCE and Mr. Norris’s TSA, Defendant denied Plaintiff’s LTD benefits.
Plaintiff again appealed and submitted updated medical records. In reviewing Plaintiff’s appeal, Defendant requested that Plaintiff undergo an Independent Medical Examination (“IME”) through a third-party vendor, Dr. Donald Lee, Board Certified in Occupational Medicine and a Qualified Medical Examiner.
Considering Dr. Lee’s restrictions and limitations, Cindy A. Herzog, MS, CRC, a Rehabilitation Specialist, performed another TSA on November 18, 2016. Ms. Herzog found that Plaintiff could perform two other occupations in Fremont, California based on a yearly wage requirement of $46,916.04: (1) Purchase-Price Analyst, and (2) Repair-Order Clerk.
As part of her secondary appeal, Plaintiff provided video statements from her and her partner, declarations from friends, colleagues, and family members, medical records, treating doctor opinion letters, and a Social Security Disability benefits award in support of her claim. In addition, she provided reports from a two-day FCE and Job Simulation Assessment (“JSA”).
Despite this evidence, Defendant upheld its termination of Plaintiff’s LTD benefits on August 9, 2017. Defendant’s denial of Plaintiff’s secondary appeal was based in part on “independent” medical reviews conducted in July 2017 by Dr. Louise Banks, M.D., Board Certified in Occupational Medicine and Internal Medicine, and Dr. Laila Laitman, Board Certified in Psychiatry. Considering the restrictions and limitations set forth by Dr. Banks, Tony Miller, MS, CRC, identified two occupations meeting the Plan’s wage requirement in the Fremont labor market: (1) Expediter, and (2) Administrative Assistant.
The plaintiff filed her lawsuit approximately one month after Cigna’s final administrative decision to uphold its termination of Plaintiff’s benefits.
Legal Standard of Review: The parties agreed that the Court would apply a de novo standard to evaluate Cigna’s denial of LTD benefits under the Plan, which meant that the Court “does not give deference to the claim administrator’s decision, but rather determines in the first instance if the claimant has adequately established that he or she is disabled under the terms of the plan.” In other terms, the Plaintiff had to show by a preponderance of evidence that she was entitled to ongoing LTD benefits under the Policy.
The Court Rules in Favor of the Plaintiff (the Claimant): The Court found that Plaintiff’s medical records support a finding of disability under the Plan:
- “Dr. Erasmus’s findings from 2016 corroborate the continuing and degenerative nature of Plaintiff’s condition. “
- In addition to the treatment records detailed above, Dr. Erasmus’s January 11, 2016 progress note describes Plaintiff’s “more prominent” and “increasingly severe” cervical pain.
- In a report dated November 23, 2016, Dr. Erasmus details a “degeneration of [Plaintiff’s] C3-4 disc with an anterior osteophyte developing.”
The Court concluded, “These findings support Plaintiff’s claim that her cervical and spinal pain is disabling, and worsening over time.”
Cigna’s Arguments: First, Cigna argued that the restrictions and limitations set forth by Drs. Mahawar and Erasmus are consistent with sedentary capacity, or the ability to do a sit-down desk position. The Court rejected this argument: “The Court is persuaded that Plaintiff’s sitting capacity falls in the lower half of this spectrum, considering: (1) Dr. Mahawar’s consistent prior finding that Plaintiff could not sit for more than 1 hour without a break of 15 minutes; and (2) his subsequent opinion that Plaintiff could only “sit or stand for less than 2 hours in an 8-hour working day.” … Independent of Plaintiff’s sitting capacity, Plaintiff’s severely restricted use of her hands, and her inability to perform repetitive movements support her claim to disability.”
Cigna then argued that components of Dr. Erasmus’s November 2016 report are based on Plaintiff’s “subjective” complaints. However, the Court found that Dr. Erasmus’s independent evaluation of Plaintiff, including his reviews of her MRIs, corroborates Plaintiff’s account of her pain. Moreover, irrespective of corroboration, the Court found that the consistency and severity of Plaintiff’s complaints and her pursuit of medical treatment over time support her claim of disability.
Next, Cigna argued that Plaintiff’s conditions were not continuous. The Court found that Cigna’s reliance on extraneous records was unpersuasive.
The Court further found: “Though not required, Plaintiff’s April 2017 FCE/JSA provides objective evidence of disability under the Policy.” In response, Cigna asserted that Plaintiff’s two day FCE/JSA was unreliable because it was purportedly based on Plaintiff’s self-reports, and purportedly contradicted by time-concurrent records. The Court found that argument unpersuasive for two reasons. First, the FCE contained numerous objective measurements of functional capacity. Second, the Court determined that Cigna’s presentation of Plaintiff’s medical records lacked credibility. The Court held, “The consistency and severity of these reports, in addition to Plaintiff’s April 2017 FCE/JSA, favor a finding of disability under the Policy.”
This claim was different than most in that the Plaintiff highlighted the insurance company’s own experts as evidence against the insurance company’s findings. Here, the Plaintiff argued that Cigna’s “independent” reviews supported her claim to LTD benefits, including the Blue FCE, Dr. Lee’s IME, Defendant’s TSAs, and Defendant’s other independent reviews. The Court reviewed all of the evidence and concluded: “Considering the reports of Plaintiff’s own physicians and the reviews obtained by Defendant, the preponderance of the medical evidence lodged in the record supports Plaintiff’s claim to LTD benefits.”
The Social Security Disability Determination:
The Court held that “Though not binding on the Court, the Court can consider Plaintiff’s award of Social Security Disability benefits for its persuasive value.”
Plaintiff’s Self-Report and Reports of Third-Party Witnesses:
Finally, the Court held that Plaintiff’s own statement and the statement of third-party witnesses supported a finding of disability under the Policy: “Plaintiff’s son, daughter, cousin, co-worker, and aunt describe Plaintiff’s debilitating chronic pain, the incapacitating side-effects of her medications, and the impact of these ailments on their lives. …. These statements support Plaintiff’s claim that her accident fundamentally altered her personality, restricted her ability to function, and negatively impacted her quality of life.”
Summary: All in all, this was a great win in favor of the disabled claimant against the insurance company.[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: