We appeal wrongful long term disability insurance and Social Security Disability denials.

Cigna Disability Insurance and the Cigna LTD Appeal Process

cigna long term disability insurance attorney

Long term disability insurance is intended to protect an employee from the loss of income in the event that he or she is unable to work for an extended period of time due to a disabling illness, injury, or accident. A Cigna long term disability plan provides that a portion of covered income is replaced and paid directly to the disabled employee. According to some estimates, the average employee with a long term disability misses as much as two and one-half (2.5) years of work. In recent years, Cigna has gained a reputation for denying large numbers of claims for long term disability benefits by requiring additional “objective information”, and then denying the claims when the claimants do not provide such documentation. The claimant’s benefits may be reinstated if they go through the Cigna LTD appeal process, but many appeals are denied as well. Having an attorney’s assistance can dramatically improve your chances of having your appeal approved, and they can assist you in filing a lawsuit if Cigna upholds the denial.

Cigna Has a History of Denying or Terminating Legitimate Claims

In 2013 Cigna entered into a multi-state settlement with the insurance commissioners of five U.S. States for improper long term disability 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.  As further detailed below, 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.

Allegations Against Cigna

The insurance departments of California, Connecticut, Maine, Massachusetts, and Pennsylvania conducted individual claims examinations of Cigna’s disability insurance claims handling practices.

The following were some of the specific allegations against Cigna:

  • 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 disability benefits 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.

Claim Handling Irregularities

  • 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 California Insurance Commissioner Dave Jones issued the following statement after the settlement:

“This case involves long term disability claims and is an important win for California consumers. … When people are injured or disabled, it is particularly important that their claims are handled quickly and fairly. The agreement with CIGNA puts into place more effective claim handling procedures, which will ensure consumer protection for policyholders.”

Under the settlement agreement, the Cigna Group is required to:

  • Enhance claim procedures to improve the claims handling process to benefit current and future policyholders.
  • Establish a remediation program in which the companies’ enhanced claim procedures will be applied to certain previously denied or adversely terminated claims for residents of states whose insurance commissioners also signed the settlement agreement.
  • Participate in a 24-month monitoring program conducted by the insurance departments of the five lead states in the action involving random sampling and ongoing consultation.
  • Undergo a re-examination upon completion of the monitoring period.
  • Pay fines and administrative fees totaling $1,675,000 to the five lead state states, which are California, Connecticut, Maine, Massachusetts, and Pennsylvania.

“Enhanced” Disability Claim Process

The “enhanced” claim procedures Cigna agreed to adopt include the following:

  • Give more appropriate consideration to awards of Social Security Disability Insurance (SSDI) benefits;
  • Gather and analyze medical records for the claimant’s full medical history;
  • Enhanced use and selection of External Medical Resources; and
  • Provide full and complete documentation to its various vocational and medical reviewers.

The Cigna companies are now re-evaluating certain claims and have set aside $77 million for projected payments to policyholders across the nation whose claims were not handled properly. Cigna is also paying a $500,000 penalty directly to the California Department of Insurance in addition to $150,000 to reimburse the department for the cost of ongoing monitoring required under the settlement agreement.

Submitting a Disability Claim to Cigna

If you are unable to work due to sickness or injury, and you have a Cigna disability plan, you must let Cigna know right away. Cigna’s website has the following instructions for filing a disability claim:

Who to Contact

  • Your employer: On or before your first day out of work, let your employer know when and for how long you expect to be absent from work.
  • Cigna:
    • For STD benefits, if you know that you will be out of work for more than seven days in a row, let us know before your seventh day out of work by filing a claim over the phone or by completing and returning the claim form online, by fax, by email or postal mail. If your plan allows for coverage before seven days, report your claim as soon as possible.
    • For LTD benefits, when possible, notify us at least 30 days before you will be unable to work. If your need for LTD benefits was unexpected, such as if you were seriously injured in a car accident, contact us as soon as possible. If Cigna has already approved your claim for short-term disability coverage, the claim will automatically be started for you.

Information to Provide

To avoid a delay in processing your claim be sure to submit:

  • Your health care provider’s (doctor or hospital) name, address, and telephone number;
  • Your last day worked, or date of injury or onset of illness;
  • The dates of your first, last and next visit to the doctor;
  • Your supervisor’s name, telephone number, and email address; and
  • The amount of money (if applicable) you are receiving from other sources (e.g., Workers’ Compensation, Social Security, state disability, or pension).

How Do I Submit My Claim?

Per Cigna’s website, you can submit your claim in one of the following ways:

Cigna’s Definition of Disability

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

1. unable to perform the material and Substantial duties of his or her Regular Occupation; and

2. unable to earn 80% or more of his or her lndexed 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 and substantial duties of any occupation for which he or she is, or becomes qualified based on education, training or experience; and2. unable to earn 60% or more of his or her Indexed Earnings. The Insurance Company will require proof of earnings and continued Disability. “

How Much Does Cigna Disability Pay?

Most policies will pay 60 percent of your insured pre-disability earnings (reduced by deductible income from other sources such as Social Security or Worker’s Compensation) while out due to an approved disability. Most LTD policies do not take effect until after an “elimination period”, which is typically a six-month waiting period. After the elimination period, if the claimant remains disabled as defined by the policy, then benefits will be paid.

Video Surveillance by Cigna

Insurance companies do hire private investigators to conduct video surveillance, and Cigna is no exception. Surveillance may include following you for the entire day while you are on your daily errands, following you to doctor’s appointments, parking outside your house, and recording you. Long Term Disability claimants (and recipients) should exercise extreme caution when interacting with anyone they suspect to be an investigator. If you are observed participating in activities that are inconsistent with your medical impairments, the insurance company may find that your condition has improved and may discontinue your benefits.

How Ortiz Law Firm Helps with the Cigna LTD Appeal Process

At the Ortiz Law Firm, we believe that no one who is unable to work due to an injury or disability should be denied the benefits they are entitled to receive under their Cigna Disability Insurance policy. With over a decade of experience in representing the disabled in insurance claims across the United States, experienced attorney Nick Ortiz has the skill and insight needed to help you address a wide range of issues relating to your claim for Cigna disability benefits.

Many disability claimants choose to file their initial claim for long term benefits alone, but even a “slam dunk” case that is well supported by medical evidence may be denied. Luckily, a claim denial is not the end of the road. Many Cigna disability insurance policyholders have contacted us regarding Cigna’s challenges to their claims for benefits. We represent claimants whose applications for LTD benefits were denied. But we also represent claimants who were being paid benefits that were suddenly terminated. Having our assistance can dramatically improve your chances of having your appeal approved if your application is denied. We work closely with our clients and offer legal advice at each in the claims process. We assist our clients in:

  • Helping you understand the reason for your denial;
  • Gathering necessary evidence for the appeal, including medical records, medical bills, 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 claim file in the manner that offers the best chance of approval;
  • Completing the appeals paperwork; and
  • Filing your appeal within the allotted time frame.

Our goal is to document your disability in a manner that clearly demonstrates your impairments and your qualification for benefits. We will work with you to gather the appropriate evidence and documentation to satisfy the requirements of your disability plan and will work diligently to address any purported deficiencies Cigna found with your documentation and paperwork as we move through the Cigna LTD process.

How Do I File an Appeal with Cigna?

Many Cigna disability claims are denied or terminated (cut-off after having previously been approved), unfortunately. A disability claim denial is not the end of your claim rights. You usually have the right to submit one or two internal appeals to Cigna.

Understand Your Denial Letter

The first step in the Cigna LTD appeal process is to understand why your claim was closed so that you can dispute the insurance companies’ decision. You should receive your denial letter from Cigna shortly after your claim is closed. Carefully review the reasons given for the denial so you can determine how to proceed with your appeal. For instance, if you did not submit all the required claim forms Cigna may have denied your claim for non-compliance.

Another example is if you were denied because your medical provider did not submit a statement to Cigna. Once you have submitted your claim for benefits, Cigna will request an Attending Physician Statement. If your medical provider does not submit a statement, or if the limitations and restrictions on the completed statement will not prevent you from performing your “own occupation”, then your claim will likely be denied.

Request Your Claim File

The next step in the Cigna LTD appeal process is to request a copy of your claim file in writing from your LTD insurance company. In accordance with federal law, the insurance company is required to provide you with a free copy of your entire claim file if your claim has been denied or terminated. You’ll need to review your claim file to see if all your medical evidence has been added to the file, and if not, you have an opportunity to submit additional evidence with your appeal. If you file a lawsuit against the insurance company in federal court, the judge will be limited to considering only the evidence that was in your claim file at the time the claims handler issued his or her final decision. That means you should “pack” or “stack” the record with favorable evidence during the administrative appeals process.

Obtain and Submit Medical Evidence

The third and final step in the Cigna LTD appeal process is to obtain and submit medical evidence. The reason for the denial as stated in your Cigna disability denial will help you determine what specific evidence you need to submit with your appeal, but it is always a good idea to submit any new medical evidence (such as visit notes from recent doctors appointments) that supports your claim. Although Cigna likely had you sign an Authorization to Obtain Information form, it is still your responsibility to obtain and submit any medical evidence that is relevant to your claim. There is usually a time limit to submit proof of loss or proof of claim, and if Cigna does not receive your medical records within a certain amount of time your appeal will be denied.

You do not have to work with an attorney to file an appeal, but the Ortiz Law Firm will help you understand the reason behind Cigna’s decision to deny or terminate your claim for benefits, obtain your claim file from Cigna, and obtain medical evidence to submit in support of your appeal. For those of you who are looking to file your own appeal, we have even more detailed information about how to appeal an LTD denial.

Can I File a Lawsuit If The Cigna LTD Appeal Process Fails?

In some cases, we are successful in having Cigna put the claimant “on claim”, which means that the claim was approved, and benefits were paid during the internal appeals process with Cigna’s claims department without resorting to a lawsuit. In other instances, however, Cigna may continue to deny your claim. Should the internal appeals process fail, you have the right to file an ERISA lawsuit to have your case reviewed by a federal judge. We will help you file the ERISA suit, and prepare all necessary documentation for the court review process.

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Contact a Cigna LTD Lawyer for Help with the Cigna LTD Appeal Process

Nick A. Ortiz is a Cigna long term disability insurance lawyer in Pensacola, Florida, and founder of the Ortiz Law Firm. Mr. Ortiz has successfully represented numerous Cigna disability insurance policyholders in their fight to obtain or hold onto their long term disability benefits.

If you are unable to work due to a serious injury or disability and Cigna is denying your long term disability insurance carrier, or if Cigna has terminated your claim prematurely, then you may be in for a fight to obtain the benefits you deserve. A Cigna long term disability lawyer can help you prepare an ERISA appeal. Contact our office online or call us at (888) 321-8131 to schedule a free case evaluation with Mr. Ortiz to learn more about how the Ortiz Law Firm can help with the Cigna LTD appeal process.

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