This 66-year-old Senior Internal Auditor for Navy Federal Credit Union developed a major depressive disorder which prevented him from performing his job duties which required a very high level of cognitive function. His claim was supported by his health care providers, but Cigna denied the claim on the basis that (1) there was “no functional impairment provided; (2) “better memory and increased energy” had been documented on a recent office visit and “you were able to complete activities of daily living which is suggestive of a functional capacity.”
The claimant first appealed on his own. That appeal was denied as almost no claimant ever wins an ERISA appeal submitted without experienced ERISA counsel.
We were retained and an extensive investigation revealed that, over time, the claimant’s job reviews by his supervisors clearly demonstrated that his performance was impacted by his depression. Cigna had never asked for this information nor suggested that the claimant obtain it.
A hallmark of ERISA disability law is that every case must begin with a detailed analysis of what it is the claimant actually does at his/her job. Insurance companies will often try to box every claimant who has an office job into one “job category:” sedentary.
The appeal also attacked the wholesale “cherry-picking” of the medical record by Cigna and the outright dismissal of the opinions of the treating doctors. Generally, an insurance company does not have to give deference to the opinion of the treating physician (and this is different from Social Security law), but it must at least consider and evaluate those opinions. The appeal pointed out that Cigna had not done so.
Cigna has continued to uphold the denial of the short-term disability claim. However, when the same claim file was presented to the long-term disability section of Cigna, that group approved the claim, paid the claim and paid the last two years of benefits.