Cigna, Life Insurance Company of America (LINA), and New York Life
Short term and long term disability insurance is intended to protect you from a loss of income in the event you are unable to work due to a disabling illness, injury, or accident. If you purchased disability coverage from Cigna—or its affiliate Life Insurance Company of North America (LINA)—it provides that a portion of covered income is replaced and paid directly to the employee.
However, in recent years, Cigna disability denials have become more and more common. Cigna/LINA has gained a reputation for denying a large number of legitimate disability claims. In 2013, Cigna entered into a settlement with the insurance commissioners of five U.S. States for improper claims handling practices. The settlement came after the insurance departments’ investigation into Cigna’s improper denials of long term disability claims and wrongful termination of existing benefit claims.
Cigna Group Insurance has since been acquired by New York Life and rebranded as New York Life Group Benefit Solutions. The rest of this page uses the company name Cigna, but the information also applies to claims that are now being processed under the company name New York Life Group Benefit Solutions.
If your short term or long term disability claim under a Cigna or LINA policy was denied or terminated, contact us for a free consultation. We have experience going up against Cigna, New York Life, and many other major insurance companies. Call our office at (888) 321-8131 to get legal help today.
Top Reasons Cigna Denies Claims
Allegations Against Cigna/LINA
The insurance departments of California, Connecticut, Maine, Massachusetts, and Pennsylvania conducted individual claims examinations of Cigna’s disability claims handling practices. Some of the specific allegations against Cigna included:
- Failing to adopt and implement reasonable standards for the prompt investigation and processing of disability insurance claims;
- Failing to disclose to claimants pertinent facts or insurance policy provisions relating to coverage issues;
- Unreasonably denying claims where it knew that the information it required to approve the disability claim existed, but it did not obtain or review the information prior to making the denial decision;
- Failing to perform any functional testing of its own, or to conduct a peer review of medical records on file;
- Failing to consult with health care professionals with appropriate training and experience in the field of medicine relating to the underlying disabling condition;
- Wrongfully terminating claims during the “any occupation” definition of disability policy period without performing a transferable skills analysis and labor market survey to identify alternate occupations appropriate to the respective claimants based on their restrictions, limitations, education, training, and experience;
- Failing to provide complete information from the claim file to the health care expert performing a medical review of the records;
- Failing to clarify a claimant’s restrictions and limitations when appropriate with the attending physician who was supporting disability.
- Failing to give due consideration to the medical findings of independent physicians;
- Discounting information provided by Social Security Disability decisions; and
- Failing to give appropriate consideration to a claimant’s workers’ compensation records.
The settlement required Cigna to improve their claims handling processes and establish a program to review long term disability claims that had been improperly denied or terminated. Cigna set aside $77 million for projected payments to policyholders whose claims were not handled properly.
Despite this settlement and other major litigation against Cigna/LINA, legitimate disability claims continue to be denied or terminated inappropriately.
What to Do After Receiving a Denial Letter from Cigna
If Cigna denies your long term disability claim, you are not alone. A vast majority of claims are denied by Cigna, but this is not the end of the road, and you should not give up. You have the right to appeal the wrongful denial or termination of your disability claim.
Understand Why Your Disability Claim Was Denied
The first step in appealing a Cigna disability denial is to understand why Cigna denied your claim. You cannot argue effectively against the decision if you do not understand the reasoning behind it. Carefully review the Cigna denial letter until you understand why Cigna denied your claim and the evidence needed to overturn the decision. If you’re unsure, speak with a long term disability attorney right away.
You Are Unable to Work Due to a Pre-Existing Condition
Most insurance companies include a pre-existing condition limitation in their policies, and it is one of the most common reasons for long term disability denials. The following is a quote from a Cigna denial letter that cited the pre-existing condition limitation:
The Insurance Company will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Pre-existing Condition.
A “Pre-existing Condition” means any Injury or Sickness for which the Employee incurred expenses, received medical treatment, consulted with a health professional, or took prescribed drugs or medicines, within 3 months immediately preceding the most recent effective date of insurance.
The Pre-existing Condition Limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of Disability that begins after an Employee is covered for at least 12 months after your most recent effective date of insurance, or the effective date of any added or increased benefits.
Many insurance companies attempt to misuse the pre-existing condition limitation to deny claims. Our team has extensive experience defending disability claims that were wrongfully denied by their insurer due to a pre-existing condition limitation.
You Did Not Meet the Definition of Disability Throughout Your Elimination Period
Most disability insurance policies also have an elimination period, which is the period of time you must be continuously disabled before you qualify for benefits. Cigna may claim that you were only unable to work for part of the elimination period, and therefore, are not eligible for benefits.
Here is an example from a Cigna/LINA disability insurance policy:
The Elimination Period is the period of time an Associate must be continuously Disabled before Disability Benefits are payable. The Elimination Period is shown in the Schedule of Benefits. A period of Disability is not continuous if separate periods of Disability result from unrelated causes.
Source: Cigna/LINA Disability Insurance Policy
You Do Not Meet the “Any Occupation” Definition of Disability
Even if you are initially approved for benefits, your claim could be terminated at a later date. Under most policies, the definition of disability will change from “own occupation” to any occupation” after a specific period of time. Under the new definition, you must prove that you are unable to perform a different job.
Here is an example from a Cigna/LINA policy:
After benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is:
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
Unable to earn 60% or more of his or her Indexed Earnings.
Source: Cigna/LINA Disability Insurance Policy
Request Your Claim File
The next step in appealing a Cigna disability denial is to request a copy of your claim file and policy. You want to review your file to see what evidence was used to decide your claim. Cigna likely had you sign an Authorization to Obtain Information form, but that does not guarantee that they obtained all of your medical records.
If Cigna conducted any independent physician consultant reviews of medical records, conducted video surveillance, or obtained any other evidence while evaluating your claim, it will also be included in your file.
Obtain and Submit Medical Evidence
The third and final step in appealing a Cigna disability denial is to obtain and submit medical evidence. The reasoning behind the decision, as stated in your denial letter, will help you determine what specific evidence you need to submit with your appeal. Generally speaking, it is always a good idea to submit any new evidence (such as a statement from your doctor or visit notes from recent doctors appointments) that supports your claim.
Experienced Disability Attorney Fights CIGNA/LINA Long Term Disability Claim Denials
At the Ortiz Law Firm, we believe that no one who is unable to work due to an injury or illness should be denied the benefits they are entitled to receive under their insurance policy.
With over a decade of experience in representing individuals across the United States, long term disability attorney Nick Ortiz has the skill and insight needed to help you address a wide range of issues relating to your Cigna long term disability claim.
We do not fear Cigna or any other big insurance companies, and our team will fight to ensure that you long term disability denial is overturned. We work closely with our clients and offer legal advice at each in the claims process. We assist and support our clients by:
- Helping you understand the reason for your denial;
- Gathering necessary evidence for the appeal, including medical records, job descriptions, bank statements and pay stubs;
- Obtaining doctors’ opinions as to your limitations due to your medical condition(s);
- Understanding the requirements of your long term disability policy, and helping you gather the documents necessary to satisfy your “proof of loss”;
- Documenting your medical conditions in the manner that offers the best chance of approval;
- Completing the appeals paperwork; and
- Filing your appeal within the allotted time frame.
You do not need an attorney to file your appeal, but working with an attorney can dramatically improve your chances of having your appeal approved. For those of you who are preparing your own appeal, we encourage you to check out our free step-by-step guide to appealing a disability insurance claim denial. The guide includes templates to appeal, request more time, request your files from the insurance carrier and your health care providers, and residual functional capacity forms for your doctors.
Can I Sue Cigna/LINA For Refusing to Pay My Long Term Disability Benefits?
The short answer is, it depends. If you have an ERISA policy (most employer purchased group plans are governed by ERISA), you are required to exhaust your administrative appeals before filing a lawsuit. Most policies require you to submit one appeal, and you may also have an opportunity to submit a second, optional appeal. Under some policies, the second appeal is required. ERISA claims have very strict requirements that you must adhere to. This is one of the many reasons you should obtain a copy of your policy during the appeal process.
If you have a non-ERISA policy, you may not be required to file an appeal before filing a lawsuit against Cigna/LINA. However, in some cases, it may be beneficial to go through with the appeal. If you’re unsure how you should proceed, consider requesting a free consultation. An experienced attorney, like you will find at Ortiz Law Firm, will help you determine what type of policy you have and whether it is in your best interest to submit an optional appeal. There is no obligation to hire our firm, and you will get answers to your questions.
Get Help With Your Cigna Claim From an Experienced Cigna Disability Lawyer
If you are unable to work due to a serious injury or disability and Cigna decides to deny your long term disability benefits, you may be in for a fight to obtain your LTD benefits. Let Ortiz Law Firm pick up the fight to reverse Cigna’s denial and obtain the benefits you deserve.
Nick A. Ortiz is a long term disability insurance lawyer in Pensacola, Florida, and founder of the Ortiz Law Firm. Mr. Ortiz has successfully represented Cigna disability policyholders across the United States in their fight to obtain or hold onto their long term disability benefits.
We offer a free consultation to claimants whose Cigna long term disability claims have been wrongfully denied or terminated. Call our office at (888) 321-8131 to schedule your free consultation today.