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:

  1. 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.
  2. 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.
  3. 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.
  4. CIGNA made no proper assessment of our client’s occupational duties and had instead merely labeled the occupation “sedentary.”
  5. 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.