{"id":7461,"date":"2020-04-06T20:29:07","date_gmt":"2020-04-07T01:29:07","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7461"},"modified":"2024-01-04T17:39:07","modified_gmt":"2024-01-04T22:39:07","slug":"sangha-v-cigna-court-rules-plaintiffs-records-support-a-finding-of-disability","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/sangha-v-cigna-court-rules-plaintiffs-records-support-a-finding-of-disability\/","title":{"rendered":"Sangha v. Cigna &#8211; Court Rules Plaintiff\u2019s Records Support a Finding of Disability"},"content":{"rendered":"<p>In this case, the U.S. District Court for the Northern District of California ruled in favor of Plaintiff Sarabjit Sangha and ruled against <a href=\"https:\/\/www.nickortizlaw.com\/insurance-companies\/cigna-lina\/\">Cigna Life Insurance Company of New York<\/a>. Specifically, the Plaintiff appealed Cigna\u2019s denial of her <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/\">long term disability (\u201cLTD\u201d)<\/a> benefits. After reviewing briefs submitted by both parties, the Judge overturned Cigna\u2019s denial of LTD benefits.<\/p>\n<p><strong>Plaintiff\u2019s Background: <\/strong>Since August 2010, Sangha worked as a Buyer\/Subcontractor Administrator for Loral Space &amp; Communications Inc.<\/p>\n<p><strong>Plaintiff\u2019s Disabilities: <\/strong>Sangha suffered from <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/pain-disorders\/\">chronic pain<\/a> secondary to cervical <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/degenerative-disc-disease\/\">degenerative disc disease<\/a> 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\u00a0<a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/sciatica\/\">sciatica<\/a>, probable opioid dependency, chronic myofascial pain syndrome, and displacement of cervical intervertebral disc without myelopathy.<\/p>\n<p><strong>Definition of Disability: <\/strong>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.<\/p>\n<p>Under the terms of this Cigna contract, an employee is considered \u201cdisabled\u201d under the Policy if:<\/p>\n<blockquote><p>Because of Injury or Sickness,<\/p>\n<p>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<\/p>\n<p>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.<\/p><\/blockquote>\n<p><strong>Procedural History and Individuals Used By Cigna to Try and Deny Claim: <\/strong>Under this definition, Cigna initially approved benefits from November 19, 2011, to October 29, 2012.<\/p>\n<p>Cigna had the claim reviewed by:<\/p>\n<ul>\n<li>Nurse Case Manager Nancy Lescher and<\/li>\n<li>Associate Medical Director Dr. Penny Chong, M.D., Board Certified in Internal Medicine.<\/li>\n<\/ul>\n<p>Predictably, both of these reviewers found that Plaintiff\u2019s limitations and restrictions were not supported and Cigna denied the claim for benefits beyond October 29, 2012.<\/p>\n<p>Plaintiff appealed, submitting additional information in support of the claim.<\/p>\n<p>Cigna had the claim reviewed by more \u201cindependent\u201d providers:<\/p>\n<ul>\n<li>MES Solutions, a third-party vendor;<\/li>\n<li>Dr. Mark D. Watson, M.D. Board Certified in Physical Medicine and Rehabilitation; and<\/li>\n<li>Melissa Mendez, a Rehabilitation Specialist.<\/li>\n<\/ul>\n<p>Surprisingly, Ms. Mendez found that the restrictions and limitations provided by Dr. Watson were not consistent with the physical demands of Plaintiff\u2019s occupation and Cigna overturned its previous denial of Plaintiff\u2019s disability benefits.<\/p>\n<p>Defendant paid Plaintiff LTD benefits for a few more months. During this time, Plaintiff continued her treatment and Defendant continued its review of Plaintiff\u2019s 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.<\/p>\n<p>Cigna also had Ms. JoAnn Orozco, a Nurse Case Manager, review Plaintiff\u2019s updated records. Again, not surprisingly, Ms. Orozco found that there was an \u201coverall lack of significant physical exam findings to support a functional loss.\u201d Dr. Chong came back into the picture again and he concluded that \u201congoing functional loss was not demonstrated.\u201d By her own admission, Dr. Chong found \u201cno time-concurrent exam notes available for review,\u201d and that medication side effects \u201cwere not reported or observed.\u201d<\/p>\n<p>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\u2019s pain, Dr. Mahawar \u201crecommended 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.\u201d Dr. Mahawar also completed a \u201cPhysical Ability Assessment\u201d (\u201cPAA\u201d), wherein Dr. Mahawar specified Plaintiff\u2019s 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 \u201coccasionally,\u201d that is, for 0 to 2.5 hours per day. Dr. Mahawar found that Plaintiff could return to \u201csedentary work only\u201d on July 15, 2014, with specific restrictions including no lifting more than 10 pounds occasionally, and minimal twisting.<\/p>\n<p>To review Plaintiff\u2019s records, including Dr. Mahawar\u2019s findings, CIGNA retained Dr. Charles Brock, M.D. Dr. Brock evaluated Plaintiff\u2019s treatment records. Based on this medical documentation, Dr. Brock concluded:<\/p>\n<blockquote><p>\u201cThe 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.\u201d<\/p><\/blockquote>\n<p>CIGNA overturned its prior denial of Plaintiff\u2019s LTD benefits under the \u201cany occupation\u201d standard based in part on Dr. Brock\u2019s review.<\/p>\n<p>Following the reinstatement of Plaintiff\u2019s LTD benefits, Plaintiff continued her pain management treatment plan, including epidural steroid injections, trigger point injections, and pain medications prescribed by Dr. Mahawar. Plaintiff\u2019s chief complaints during this period were chronic <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/neck-pain\/\">neck pain<\/a>, <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/back-pain\/\">lower back pain<\/a>, and pain in her right shoulder and arms.<\/p>\n<p>On January 24, 2016, Defendant again reviewed Plaintiff\u2019s LTD benefit eligibility. Plaintiff submitted her medical records, and underwent a Functional Capacity Evaluation (\u201cFCE\u201d) arranged by Cigna. The FCE was performed by Jonathan Blue, DPT, on May 12, 0216. Mr. Blue found that Plaintiff \u201cwas limited in her ability to tolerate maintaining static positions for prolonged periods of time throughout the test.\u201d<\/p>\n<p>Based on the limitations and restrictions set forth in the Blue FCE, Randy Norris, MS, CRC, CCM, conducted a Transferable Skills Assessment (\u201cTSA\u201d) dated May 17, 2016. Mr. Norris found two occupations in the Fremont, California labor market that purportedly satisfied Plaintiff\u2019s restrictions and the Policy\u2019s wage requirement: (1) Financial-Aid Counselor, and (2) Procurement Engineer. Following the Blue FCE and Mr. Norris\u2019s TSA, Defendant denied Plaintiff\u2019s LTD benefits.<\/p>\n<p>Plaintiff again appealed and submitted updated medical records. In reviewing Plaintiff\u2019s appeal, Defendant requested that Plaintiff undergo an<a href=\"https:\/\/www.nickortizlaw.com\/independent-medical-examination-ime\/\"> Independent Medical Examination (\u201cIME\u201d)<\/a> through a third-party vendor, Dr. Donald Lee, Board Certified in Occupational Medicine and a Qualified Medical Examiner.<\/p>\n<p>Considering Dr. Lee\u2019s 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.<\/p>\n<p>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 (\u201cJSA\u201d).<\/p>\n<p>Despite this evidence, Defendant upheld its termination of Plaintiff\u2019s LTD benefits on August 9, 2017. Defendant\u2019s denial of Plaintiff\u2019s secondary appeal was based in part on \u201cindependent\u201d 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\u2019s wage requirement in the Fremont labor market: (1) Expediter, and (2) Administrative Assistant.<\/p>\n<p>The plaintiff filed her lawsuit approximately one month after Cigna\u2019s final administrative decision to uphold its termination of Plaintiff\u2019s benefits.<\/p>\n<p><strong>Legal Standard of Review: <\/strong>The parties agreed that the Court would apply a\u00a0<em>de novo<\/em>\u00a0standard to evaluate Cigna\u2019s denial of LTD benefits under the Plan, which meant that the Court \u201cdoes not give deference to the claim administrator\u2019s 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.\u201d In other terms, the Plaintiff had to show by a preponderance of evidence that she was entitled to ongoing LTD benefits under the Policy.<\/p>\n<p><strong>The Court Rules in Favor of the Plaintiff (the Claimant): <\/strong>The Court found that Plaintiff\u2019s medical records support a finding of disability under the Plan:<\/p>\n<ul>\n<li>\u201cDr. Erasmus\u2019s findings from 2016 corroborate the continuing and degenerative nature of Plaintiff\u2019s condition. \u201c<\/li>\n<li>In addition to the treatment records detailed above, Dr. Erasmus\u2019s January 11, 2016 progress note describes Plaintiff\u2019s \u201cmore prominent\u201d and \u201cincreasingly severe\u201d cervical pain.<\/li>\n<li>In a report dated November 23, 2016, Dr. Erasmus details a \u201cdegeneration of [Plaintiff\u2019s]\u00a0 C3-4 disc with an anterior osteophyte developing.\u201d<\/li>\n<\/ul>\n<p>The Court concluded, \u201cThese findings support Plaintiff\u2019s claim that her cervical and spinal pain is disabling, and worsening over time.\u201d<\/p>\n<p><strong>Cigna\u2019s Arguments: <\/strong>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: \u201cThe Court is persuaded that Plaintiff\u2019s sitting capacity falls in the lower half of this spectrum, considering: (1) Dr. Mahawar\u2019s 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 \u201csit or stand for less than 2 hours in an 8-hour working day.\u201d \u2026 Independent of Plaintiff\u2019s sitting capacity, Plaintiff\u2019s severely restricted use of her hands, and her inability to perform repetitive movements support her claim to disability.\u201d<\/p>\n<p>Cigna then argued that components of Dr. Erasmus\u2019s November 2016 report are based on Plaintiff\u2019s \u201csubjective\u201d complaints. However, the Court found that Dr. Erasmus\u2019s independent evaluation of Plaintiff, including his reviews of her MRIs, corroborates Plaintiff\u2019s account of her pain. Moreover, irrespective of corroboration, the Court found that the consistency and severity of Plaintiff\u2019s complaints and her pursuit of medical treatment over time support her claim of disability.<\/p>\n<p>Next, Cigna argued that Plaintiff&#8217;s conditions were not continuous. \u00a0The Court found that Cigna\u2019s reliance on extraneous records was unpersuasive.<\/p>\n<p>The Court further found: \u201cThough not required, Plaintiff\u2019s April 2017 FCE\/JSA provides objective evidence of disability under the Policy.\u201d In response, Cigna asserted that Plaintiff\u2019s two day FCE\/JSA was unreliable because it was purportedly based on Plaintiff\u2019s 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\u2019s presentation of Plaintiff\u2019s medical records lacked credibility. The Court held, \u201cThe consistency and severity of these reports, in addition to Plaintiff\u2019s April 2017 FCE\/JSA, favor a finding of disability under the Policy.\u201d<\/p>\n<p>This claim was different than most in that the Plaintiff highlighted the insurance company\u2019s own experts as evidence against the insurance company\u2019s findings. Here, the Plaintiff argued that Cigna\u2019s \u201cindependent\u201d reviews supported her claim to LTD benefits, including the Blue FCE, Dr. Lee\u2019s IME, Defendant\u2019s TSAs, and Defendant\u2019s other independent reviews. The Court reviewed all of the evidence and concluded: \u201cConsidering the reports of Plaintiff\u2019s own physicians and the reviews obtained by Defendant, the preponderance of the medical evidence lodged in the record supports Plaintiff\u2019s claim to LTD benefits.\u201d<\/p>\n<p><strong>The Social Security Disability Determination:\u00a0<\/strong>The Court held that \u201cThough not binding on the Court, the Court can consider Plaintiff\u2019s award of Social Security Disability benefits for its persuasive value.\u201d<\/p>\n<p><strong>Plaintiff\u2019s Self-Report and Reports of Third-Party Witnesses:\u00a0<\/strong>Finally, the Court held that Plaintiff\u2019s own statement and the statement of third-party witnesses supported a finding of disability under the Policy: \u201cPlaintiff\u2019s son, daughter, cousin, co-worker, and aunt describe Plaintiff\u2019s debilitating chronic pain, the incapacitating side-effects of her medications, and the impact of these ailments on their lives. \u00a0\u2026. These statements support Plaintiff\u2019s claim that her accident fundamentally altered her personality, restricted her ability to function, and negatively impacted her quality of life.\u201d<\/p>\n<p><strong>Summary: <\/strong>All in all, this was a great win in favor of the disabled claimant against the insurance company.<\/p>\n[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.]\n<p>Here is a copy of the decision in PDF: <a href=\"https:\/\/www.nickortizlaw.com\/wp-content\/uploads\/2020\/04\/Sangha_v_Cigna-USCOURTS-cand-4_17-cv-05158.pdf\">Sangha v. Cigna<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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\u2019s denial of her long term disability (\u201cLTD\u201d) benefits. After reviewing briefs submitted by both parties, the Judge overturned Cigna\u2019s denial &hellip;<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[257],"_links":{"self":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7461"}],"collection":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/comments?post=7461"}],"version-history":[{"count":0,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7461\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/media?parent=7461"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/categories?post=7461"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/tags?post=7461"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}