CIGNA Denies CFS, Fibromyalgia and Spinal Claims, We Overturn ERISA and Win Appeal
Tuesday, October 16th, 2012
Our client, a 58 year old woman, was a Senior Research Manager for a large pharmaceutical company with a history of cancer. She suffers from CFS, fibromyalgia, spinal conditions, and cognitive difficulties related to her numerous co-morbid conditions. Two of the top physicians in the Northeast treated her for CFS and fibromyalgia. She had filed for disability benefits with CIGNA and was paid during the entire “own occupation” portion of the policy, and in the beginning of the “any occupation” phase.
It was during the “any occupation” phase that she was placed under surveillance numerous times and her activities were videotaped. CIGNA’s investigators never observed her doing anything that she or her doctors had said that she could not do, but the frequency of the surveillance led us to believe that they were looking for a reason to stop paying her monthly benefits.
Six months into the “any occupation” phase, CIGNA retained MES Solutions to conduct a paper review of her medical records, but provided MES Solutions with only selected portions of the medical records and only selected portions of the surveillance videos to an unqualified paper reviewing doctor.
The MES Doctor had no qualifications in dealing with CFS or fibromyalgia that would allow him to accurately assess our client’s functionality. Given that her conditions were highly complicated, CIGNA should have, at the very least, had her records reviewed by a qualified medical doctor who could have better understood the significance of her symptoms and the correlation of her various symptoms. CIGNA failed to produce any evidence that would indicate that the MES doctor had any appropriate clinical experience or medical knowledge that would allow for a reliable assessment of our client’s disability. Instead, the doctor reported that she was not disabled, and CIGNA terminated her benefits.
The restrictions and limitations CIGNA used in this review were those restrictions and limitations imposed by the paper reviewing doctor that CIGNA hired, and not the real restrictions and limitations imposed on our client by her treating physicians.
At the same time, CIGNA conducted a vocational review which only took into consideration the physical capabilities it claimed she was capable of, and not the cognitive requirements. As a Senior Research Manager for a large pharmaceutical corporation, her duties and responsibilities required extremely high level cognitive skills. She managed a team of personnel and oversaw a multi-million drug development platform. Her position required high level decision making and analysis. These debilitating conditions made it impossible to execute the duties of her position. A computer program called OASYS was used to complete the vocational analysis, and the OASYS reports were never provided to our client.
In addition to the review by MES Solutions and the OASYS vocational analysis, CIGNA also conducted an IME which reported that our client was indeed unable to work.
This mess of a termination, if you are counting, included one paper review conducted by a non-qualified doctor of highly limited medical records and surveillance tapes, a faulty vocational review, records that were never provided to our client, and an IME that supported our client’s claim but was ignored. CIGNA’s reviews were unprofessional, incomplete and unfounded.
We fought back, working with our client’s treating physician, attacking the vocational analysis, and won. Our client is now back on claim and able to focus her attention on getting through the day-to-day challenges that her illnesses present.