The claimant was a Network planner/installer who was injured in a surfing accident in August 2014 when he fractured one of his cervical vertebrae. He then developed chronic, debilitating pain. He applied for disability benefits through his employer’s ERISA governed long-term disability policy and was denied. He then appealed his denial (internal appeal) on his own and was again denied. The plan afforded a second “voluntary” appeal and he retained counsel for that appeal.
An ERISA administrative appeal followed which argued, in large part, that CIGNA had not afforded the claimant the full and fair review guaranteed under ERISA because the file was not reviewed by an appropriate healthcare professional. The appeal argued that the insurance company’s internal medicine reviewer was not an appropriate medical professional under ERISA in light of the extensive orthopedic, pain management and neurologic treatment the claimant had received. The appeal also argued that 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 the claimant’s pain. Finally, the appeal argued that the insurance company had made no proper assessment of the claimant’s occupational duties and had instead merely labeled the occupation “sedentary.”
The appeal included an extensive analysis of ERISA caselaw, updated witness statements and additional medical documentation and literature.
CIGNA reinstated benefits.