Disability Insurance Blog

Court Finds for Disability Claimant Under De Novo Review

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Friday, February 1st, 2013

A Federal Judge in Michigan has highlighted the significance of the applicable standard of review in an ERISA long term disability insurance claim dispute, finding for the plaintiff, under a de novo standard of review, while noting that if the standard of review was abuse of discretion, he would likely have ruled for defendants.

This case, brought against CIGNA, was predicated upon the claimant’s disability resulting from autonomic dysfunction, POTS (Postural Orthostatic Tachycardia Syndrome) and syncope. CIGNA initially approved the disability insurance claim in 2006, and paid benefits for 8 months, prior to terminating the claim. On appeal, CIGNA relied upon its regularly utilized physician Dr. Mendez, who — as he typically does — found there to be “no time-concurrent documentation of significant measured physical limitations to support the extension of restrictions from regular work duties.”

After suit was filed, CIGNA agreed to pay the claimant for the duration of the own occupation period of the policy — where the determination was whether the insured could perform the duties of his work. The matter was then remanded to CIGNA to consider whether the insured could work in any occupation, a definition of disability much more favorable to the insurance company. Upon this review, CIGNA again denied benefits.

Weighing heavily toward the insured’s favor was his receipt of Social Security disability benefits, along with strong support from his treating provider. CIGNA’s efforts to cherry pick records to buttress its claim determination were found wanting, and the Court ultimately found for the insured, awarding him his prior benefits to be paid.