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

Cigna: Advice for the Difficult Cigna LTD Appeal Process

cigna long term disability insurance attorney

New York Life Insurance Company has acquired Cigna Group Insurance, which is now known as New York Life Group Benefit Solutions. We are already receiving correspondence from New York Life Group Benefit Solutions on behalf of our clients, which states that we should not notice any changes other than the new company name, which will appear in place of “Cigna Group Insurance” moving forward. Contact information for existing claims, such as phone numbers and mycigna.com remain the same at this time (unless otherwise specified on a case by case basis).

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. In this article, we’ll discuss filing an appeal, Cigna’s history of denying claims, and tips for those who are filing an initial application for 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, 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 long term disability 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 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.

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 appealing a Cigna disability denial 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.

The examples above are what we consider non-medical denials, meaning your claim was denied for a non-medical reason like not submitting the required paperwork. Even if you submit the required paperwork Cigna could find another reason to deny your claim.

Denied Due to a Pre-existing Condition

Most disability insurance policies include a Pre-existing Condition Limitation. The following is an excerpt from a Cigna denial letter

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 insurers misuse the Pre-existing Condition Limitation to deny claims, and our office has extensive experience with disability claims that were denied due to a pre-existing condition.

You Do 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 in order to qualify for benefits. Cigna may claim that you were disabled for only some of the Elimination Period, and therefore, are not eligible for benefits. Here is a quote from a Cigna 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.

Core Benefit: 26 weeks

Optional Benefit: 26 weeks

The Transition from Own Occupation to Any Occupation

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 after a period of time. Here is an example pulled from a Cigna disability insurance policy:

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:

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.

Request Your Claim File

The next step in appealing a Cigna disability denial 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 file if your claim has been denied or terminated. You’ll need to review your 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 appealing a Cigna disability denial 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 an attorney will help you understand the reason behind Cigna’s decision to deny or terminate your claim for benefits, obtain your 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.

Cigna Buyout Settlement Offers

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; and

2. 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.

Get Help with the Cigna LTD Appeal Process

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 numerous Cigna disability insurance policyholders in their fight to obtain or hold onto their long term disability benefits. We offer a free consultation to claimants who have been wrongfully denied disability benefits or whose claims for disability benefits were wrongfully terminated.

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 long term disability claim lawyer can help you prepare an ERISA appeal. Contact us online or call us at (888) 321-8131 to schedule a free consultation with Mr. Ortiz to learn more about how our firm can help with the Cigna LTD appeal process.

PinLinkedInPrint