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Court Remands Case After Finding CIGNA Failed to Properly Review Claim

Thursday, January 30th, 2014

A Federal Court in Pennsylvania has determined that CIGNA failed to follow the recommendations of its hired doctor — instead terminating a claimant who had been on claim and paid from 1997 until 2012. CIGNA failed to conduct an appropriate evaluation of the claimant, and failed to account for the recommended testing from a doctor it hired to review the records and who challenged the results of a Functional Capacity Evaluation, claiming that due to the nature of the claimant’s condition, the appropriate testing would encompass 8 hours per day over three consecutive days.

Unfortunately, CIGNA ignored this well reasoned approach to evaluating a claimant’s true level of functional capacity, eschewing such logic for a pre-determined path to terminate a long standing claimant.

The claimant, who originally went out on disability in 1997 due to Chronic Fatigue Syndrome and Lupus, had previously had her claim terminated in 2009, only to be reinstated again following an administrative appeal. The claimant had also been awarded Social Security disability benefits resulting from the same conditions upon which CIGNA had accepted liability of the claim. CIGNA had also obtained surveillance video of the claimant, which was largely benign and not indicative of much as it pertained to work capacity. While the Court noted that surveillance is an “aggressive tactic” it took no issue with it as being a prohibited claim investigative tool.

Due to its concern about the appropriate consideration of the medical issues, the Court determined that remanding the claim back to CIGNA, for the purpose of obtaining an appropriate Functional Capacity Evaluation, was the most logical course.

In our national practice, we often see claims denied and/or terminated on the basis of paper only medical reviews, rather than an actual in person examination of a claimant. We also see many cases where a flawed Functional Capacity Evaluation was conducted, and which typically fails to provide significant information to determine a claimant’s true level of sustained functionality.

Moros v. CIGNA

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