2 ERISA Long-Term Disability Denials, Two Appeals, Two Wins

This is the second time that this ERISA long-term disability claimant appealed and won a denial of benefits.

In most disability policies, an insured is paid during the first 24 months of benefits if they cannot perform their “own occupation.” After 24 months they are entitled to benefits only if they cannot work at “any occupation.”

The claimant was a senior systems analyst who became disabled after struggling with Rheumatoid Arthritis, Osteoarthritis, Dequervain’s Syndrome (similar to carpal tunnel syndrome) and myriad other related conditions.

In this case the claimant was first denied benefits during her “own occupation.” That denial was appealed and the denial was reversed and benefits reinstated. After several months of payments, however, the plaintiff entered the “any occupation” period and CIGNA again terminated benefits. CIGNA argued that even though it agreed that the claimant could not work as a “systems engineer” that she could work as a “project director.” It based its decision to deny benefits on an independent medical examination and a vocational rehabilitation expert who did a “transferable skills analysis.”

Thus a second appeal was undertaken. The principal arguments made in support of the claim included:

1. CIGNA had cherry-picked information from the IME while ignoring the conclusion;
2. There was no material difference between a “systems engineer” and a “project director” for purposes of CIGNA’s disability policy;
3. The vocational rehabilitation review and “transferable skills analysis” were unscientific and would not be accepted by a federal court;
4. CIGNA has arbitrarily ignored the claimant’s undisputed high pain levels.
5. A comparison of various physical capacity forms fills out over several years by the treating physicians showed that her condition had worsened over the years;
6. When the claim file was closely examined it was apparent that CIGNA’s own medical reviewers agreed that the claimant was disabled.

CIGNA reinstated benefits.  The expected lifetime value of the monthly benefits is $204,100.