Our client for this long term disability appeal, a network planner/installer, was injured in a surfing accident in August 2014 when he fractured one of his cervical vertebrae, developing chronic, debilitating pain. He applied for disability benefits through his employer’s ERISA governed long-term disability policy but was denied. He then individually appealed his denial (internal appeal) and was again denied. The plan included a second “voluntary” appeal and he retained counsel for that appeal.
ERISA administrative appeal:
- CIGNA had not afforded our client the full and fair review guaranteed under ERISA because the file was not reviewed by an appropriate healthcare professional.
- CIGNA’s internal medicine reviewer was not an appropriate medical professional under ERISA in light of the extensive orthopedic, pain management and neurologic treatment our client had received.
- A reasonable fiduciary could not simply ignore the well-documented complaints of pain and the opinions of the treating physicians regarding the debilitating nature of our client’s pain.
- CIGNA made no proper assessment of our client’s occupational duties and had instead merely labeled the occupation “sedentary.”
- Included an extensive analysis of ERISA case law, updated witness statements and additional medical documentation and literature
As a result of our long term disability appeal, CIGNA reinstated benefits, with an expected lifetime value of the monthly benefits is $947,394.