LINA (Cigna) Wrongly Denied Disability Benefits for Pennsylvania Nurse with Pain and Fatigue from Sjogren’s Syndrome

A Pennsylvania federal court recently found LINA wrongfully rejected a cardiac rehab nurse’s claim for long-term disability (LTD) benefits.

Sheryl Heim was a successful nurse for 12 years until she was forced to stop working due to an autoimmune disorder that caused her to experience severe pain, weakness, fatigue, and cognitive issues. Ms. Heim’s disability was supported by her treating physician’s notes, her own detailed records, and an abnormal MRI of her brain.

When she filed her claim for LTD benefits, however, LINA denied it because “the medical information does not support restrictions and limitations which would preclude you from performing your regular occupation.” This is a textbook example of boilerplate language used by insurance companies when they deny benefits without a proper analysis of the claimant’s disability.

Twice, Ms. Heim appealed LINA’s decision to deny her the benefits she deserved and provided the following, additional evidence proving she was disabled:

  • Letters from her treating doctors;
  • Her own letter detailing her condition and symptoms; and
  • Updated medical records from her treating doctors.

LINA denied both appeals, relying more on their own doctor’s opinion after conducting a file review of Ms. Heim’s medical records. Then, Ms. Heim and her attorneys were forced to file a lawsuit against LINA.

The Court’s Review of Ms. Heim’s Claim

Standard of Review

Like most claims for disability benefits, Ms. Lapidus’ claim was governed by the Employee Retirement Income Security Act of 1974 (ERISA). Generally, if you are eligible for disability benefits through your job, it is likely governed by ERISA.

Most disability policies contain discretionary language. This means insurance companies, including LINA, have discretion to determine if someone meets their definition of disability. Under ERISA, if a plan document includes discretionary language, the court will apply an arbitrary and capricious standard of review. Under this standard, the court can only rule in your favor if it finds the insurance company had no reasonable basis to deny benefits. This is a difficult standard to meet.

Here, however, the court found the “de novo” standard of review applied because LINA’s policy only required the submission of “satisfactory proof.” The court further explained this was inadequate language to trigger a deferential standard of review and, therefore, the judge was able to decide if Ms. Heim was entitled to benefits under the policy.

The Court’s Decision

The court found LINA’s decision to deny Ms. Heim’s claim for LTD benefits was wrong because:

  • An insurer may not require objective evidence to prove a condition with subjective symptoms such as pain, weakness, and fatigue;
  • Reliance on a non-examining doctor’s opinion premised on a records review alone is suspect and suggests the insurer is looking for a reason to deny benefits; and
  • LINA failed to properly evaluate Ms. Heim’s ability to perform the specific requirements of her job.

In addition to awarding LTD benefits, the court later ordered LINA to pay Ms. Heim’s attorneys’ fees. To quote the judge, “Requiring LINA to pay attorneys’ fees in cases such as this one should have a deterrent effect and I can hope that it will.”

Help from an Attorney with Expertise in Disability Insurance

Disability insurance law is complicated. If your claim for long term disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.

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