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Court Finds CIGNA’s Decision to Terminate Long Term Disability Claim was Arbitrary and Capricious

Friday, January 18th, 2013

A Federal judge in Ohio has determined that CIGNA wrongfully terminated a long term disability insurance claim, where it failed to properly consider the occupational requirements for the claimant, and where it failed to account for the claimant’s receipt of Social Security disability benefits.

The claimant, an employee of Pfizer, working as a Senior Professional Healthcare Representative (pharmaceutical sales rep), was injured when she fell horseback riding and fractured her hip. She filed a claim, which was initially accepted and long term disability benefits were paid by CIGNA for a period of time. Ultimately, however, CIGNA terminated the claim on the purported basis that the claimant could perform her prior work, a determination reached by a nurse case manager, in the face of documentation and evidence from the claimant’s doctors to the contrary.

The claimant also suffered from fibromyalgia, narcolepsy, osteoarthritis and other impairments. She was awarded Social Security disability benefits and used a CIGNA affiliated advocate — Advantage 2000 — to secure these benefits.

Despite noting that the standard of review was pro-insurer, and applying the deferential abuse of discretion standard of review, the Court determined that CIGNA abused its discretion by failing to properly consider whether the claimant could perform the duties of her occupation, and in terminating the long term disability insurance claim.

Instead, CIGNA simply evaluated whether the claimant could perform sedentary type work — myopically focused on global functionality, rather than work ability. The Court determined that CIGNA’s failure to consider the actual occupational requirements as required, and further, that CIGNA improperly required objective evidence of impairment, despite conditions which cannot be readily addressed by objective evidence (fibromyalgia).

The Court was also troubled by CIGNA’s failure to consider the award of Social Security benefits, despite mandating that the claimant pursue Social Security disability, and despite securing a financial benefit from the award of Social Security benefits.

As a result, the Court remanded the claim back to CIGNA for appropriate consideration of the issues.

Geiger v. Pfizer, Inc.

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