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Wednesday, February 28th, 2007

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Virtually every long term disability (“LTD”) plan changes the definition of disability after a short period of time, which is usually two years. After that time, instead of having to prove that you are unable to do you own job, you now have to show that you cannot do any work for which you are reasonably qualified. The insurance companies that administer LTD plans frequently terminate monthly benefits when this change in definition occurs.

A claimant retained me after CIGNA terminated his LTD benefits and had denied his appeal twice. The claimant had submitted narrative reports and records from several treating medical specialists as well as a report from a vocational expert. Despite a claim file of nearly 1,000 pages, the question was a simple one: did he have the functional capacity to perform sedentary work.

Courts had specifically instructed CIGNA that sedentary work requires the ability to sit for at least 6 hours a day and walk and stand for two hours during a work day. The claimant’s pain management specialist completed a report specifying the claimant was limited to sitting for only 1-2 hours, and standing less than 1 hour. Nonetheless, CIGNA denied the appeal because the pain management specialist previously had said that the claimant had “5/5 motor strength.” Among the many things that I pointed out on appeal is that CIGNA had approved benefits despite that finding, which showed it was not a valid excuse for terminating benefits.

When the sole basis for a denial or termination of benefits is exposed as patently invalid, insurance companies frequently develop a new reason for their decision. To avoid CIGNA from concocting a new rationale, and because no new evidence could be submitted in federal court if the final appeal were denied, I had the claimant seek updated and additional reports detailing his functional capacity from seven different physicians. The goal was to overwhelm CIGNA with the new evidence and my 15 page letter demonstrating the flaws in the termination decision.

The strategy was successful. A week earlier, after having submitted my appeal three and a half months earlier, I faxed CIGNA a demand for an answer or advised I would proceed to federal court promptly. Apparently CIGNA was so overwhelmed by all the new evidence and the detailed attack of its decision that it sent a check for all retroactive benefits without any explanation.

Unfortunately, unless an LTD appeal is overwhelming, the insurance company will usually risk going to court, where it realizes that the deck is stacked against the claimant.

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