New York Court Orders Cigna to Reinstate Producers Long-Term Disability Benefits of Producer Dealing with Chronic Pain
A New York court ordered Cigna to reinstate New York Ms. Christine Thoma’s long-term disability (“LTD”) Benefits. The court found that the medical evidence confirmed her continued disability. Thus, the court ruled Ms. Thoma was disabled under the terms of Cigna’s long-term disability policy.
This firm’s focus is on helping people like Ms. Thoma with claims for long-term disability benefits. We have fought all major disability insurance carriers. If you are having trouble with your disability insurance carrier, please call to speak with one of our experienced disability lawyers today.
Prior to becoming disabled, Ms Thoma worked as a producer for Fox. Chronic pain forced her to stop working. Her pain was a result of five back surgeries. Unable to continue working, Ms. Thoma filed a claim for long-term disability benefits with Cigna.
Ms. Thoma’s Case for LTD Benefits
Cigna approved Ms. Thoma’s long-term disability benefits and paid her monthly benefits for two years. Cigna acknowledged she was unable to work in her own occupation as a producer. However, after 24 months the LTD policy required that Ms. Thoma prove she could not work in any job. After paying benefits for 24 months, Cigna terminated her claim finding she was capable of working in seated jobs.
Cigna’s termination of benefits was based on:
- The results of an “Independent Medical Examination” (“IME”) completed by Dr. Berman
- Surveillance of Ms. Thoma
- Transferable Skills Analysis
Ms. Thoma appealed Cigna’s decision and submitted medical evidence confirming her disability. Relying on a paper based review of the records as well as another transferable skills analysis, Cigna maintained its denial of benefits.
The Court Rules Cigna’s Termination was Unlawful
Ms. Thoma filed a lawsuit against Cigna and won.
The New York court reviewed Ms. Thoma’s case de novo, meaning it did not have to give deference to Cigna decision. Under the Employee Retirment Income Security Act of 1975 (ERISA), a federal law that governs group disability claims, when the policy contains discretionary language, the court must give deference to the insurance company. This means it can only rule against the insurance company if acted entirely unreasonable in terminating benefits. This is a difficult standard to meet.
Here, the court found Cigna’s policy did not contain the necessary language. Thus, Ms. Thoma only had to prove that she was disabled. Indeed, Ms. Thoma convinced the court of her disability.
In ruling for Ms. Thoma, the court highlighted several issues with Cigna’s termination of benefits. First, Cigna noted Cigna’s reliance on Dr. Berman IME report was wrong. The court said Cigna did nothing to reconcile the difference in opinion between Dr. Berman and (i) the opinions of Ms. Thoma’s treating physicians, (ii) the medical literature, and (iii) the approval of social security disability benefits, which all supported Ms. Thoma’s disability.
The court was not persuaded by Cigna’s reliance on surveillance of Ms. Thoma showing her carrying a bag and folding chair over her shoulder. The court reasoned such activities were not inconsistent with Ms. Thoma’s disability.
In addressing Cigna’s appeal denial, the court found Cigna’s reviewing doctor did not give any explanation why his opinion was different then other physicians who had previously found her disabled. The court also found Cigna wrongfully withheld information from its vocational consultant who concluded Ms. Thoma could work in other jobs based on the report drafted by Cigna’s reviewing physician. The court noted that the vocational consultant was not given information supporting Ms. Thoma’s disability.
Ultimately, the court found the evidence made clear that Ms. Thoma remained disabled. The court ordered Cigna reinstate Ms. Thoma’s benefits.
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