Disability Denied By Cigna? How to Prevail When Cigna Won't Pay

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

TABLE OF

CONTENTS

Introduction

What Is Disability Insurance?

Short Term, Long Term, Catastrophic —

What Is The Difference?

Improve Your Chances of Winning Disability Beneﬁts

Proving Your Disability Claim

How CIGNA Determines Your RFC

(Residual Functional Capacity)

Insurers’ Claim-Denying Tactics

How Much Will Your Disability Payments Be?

How Pre-Existing Conditions Could Affect Your Beneﬁts

When Your Claim Is Denied: The CIGNA Appeal Process

Filing a Lawsuit After Losing an Administrative Appeal

Choosing the Right Disability Attorney

Marc Whitehead & Associates Will Help You Fight

Disclaimer

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

INTRODUCTION

Perhaps you experienced a bad reaction to a medical therapy that

has left you lethargic and with a compromised immune system. Or

maybe an accident around the home or on the road has left you with

limited mobility and in need of medication to deal with chronic pain.

Whatever your unique situation is, you expected your disability insurer

to provide fair and complete coverage.

Frustratingly, your experience with CIGNA has most likely been

anything but simple and easy.

Since it was formed in 1982, CIGNA has grown to become the fourth

largest provider of disability insurance in the U.S., claiming 7 percent

of the market. Its offerings include group short term and long term

disability insurance for companies with 51 or more employees. Today,

it provides disability coverage to 4.3 million people in the U.S. through

more than 5,100 employer group policies.

CIGNA’s practices have evoked controversy over the years. In 2011,

the California Nurses Association/National Nurses United charged that

the company denied 39.6 percent of all claims. In 2013, the insurance

commissioners of California, Connecticut, Maine, Massachusetts and

Pennsylvania announced they had reached a settlement with CIGNA

over its claims handling practices. The insurer agreed to re-evaluate

many denied claims and set aside $77 million to cover projected

payments to people whose claims were not handled properly. CIGNA

also paid $1.6 million in ﬁnes and fees to these ﬁve states.

We have written this book to give you a 20,000 foot perspective on

how and why to ﬁght back against your long term disability (LTD)

denial and prove your CIGNA claim. Although this isn’t legal advice,

it can help you understand how to get the money and fair treatment

you need to take care of yourself and your family, pay for therapy and

doctor’s bills, and feel more optimistic about the future.

CIGNA IS

4TH LARGEST

DISABILITY

INSURANCE

PROVIDER IN

THE U.S.

Since it was formed in

1982, CIGNA has grown

to become the fourth

largest provider of

disability insurance in the

U.S., claiming 7 percent

of the market.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

WHAT IS

DISABILITY

INSURANCE?

The concept of disability insurance is a good one: to provide

economic protection for workers who can’t remain on the job (short

term or long term) because they have suffered an injury or become

ill. Insurers introduced disability policies in the 1980s, thinking they

would be proﬁtable. But they calculated wrong. Insurers lost money

because they overpromised beneﬁts.

To dig themselves out of this hole, insurance companies began ﬁnding

ways to reduce disability payouts. This meant denying claims and re-

examining and cutting off claims that they were already paying.

As a result, many people who have paid their disability premiums

and expected coverage have been denied beneﬁts when they really

needed them.

An insurance company like CIGNA can take advantage of policy

loopholes to deny disability beneﬁts to someone who has a legitimate

injury or illness. As a policy holder, you do have the right to appeal

the company’s decision, but it’s tough to win your case unless you

understand the laws regulating disability claims.

Did you know, for example, that you do not get the opportunity to

provide new information when you are ﬁling a lawsuit about a disability

claim denial? If you don’t include all of the facts and records to support

your claim when you ﬁle an administrative appeal, you will not be able

to present them to the court if you end up suing the insurer.

That’s why it is so important to work with an attorney who handles

ERISA (Employee Retirement Income Security Act) claims on a daily

basis. You need to present your strongest arguments right from

the start if you want to be successful in claiming and receiving your

disability beneﬁts.

Did you know?

You do not get the

opportunity to provide

new information when

you are ﬁling a lawsuit

about a disability claim

denial. If you don’t

include all of the facts

and records to support

your claim when you ﬁle

an administrative appeal,

you will not be able to

present them to the court

if you end up suing the

insurer.

CASE STUDY #1: Kassa v. Plans Admin. Comm. Of Citigroup, Inc., Filed in

U.S. District Court for the District of New Mexico, June 30, 2011

In this case, Nikki Kassa, the Plaintiff, sought a judgment from a group accidental death policy. Per Court

records, “The plan administrator incorrectly determined that a bone fracture accident did not cause death

where the decedent died from complications from the accident that aggravated his cardiovascular disease.

Because the death resulted from bodily injuries caused by an accident, the death was not excluded under the

sickness exemption.”

After all was said and done, the Plaintiff succeeded in obtaining substantial beneﬁts from the insurer,

including “the policy amount, pre- and post-judgment interest, attorneys’ fees and costs.”

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

SHORT TERM,

LONG TERM,

TAST

ROPHIC

— WHA

IS THE

DIFFERENCE?

There are two ways that people usually obtain disability coverage.

First, you can obtain it on your own, through an individual policy

purchased from an insurance broker. That’s not relevant in this case,

because CIGNA does not offer individual disability policies.

The second way to obtain disability coverage is through your employer.

CIGNA sells its disability policies through employers’ group beneﬁt

policies. Not all of CIGNA’s disability plans are the same, however. The

company can and does vary the language of policies according to the

employer and the state in which it is offering the policy. The only way

to know what is actually in your policy is to get a copy of it from your

employer and read it for yourself.

Although some details may differ, there are basically three different

types of disability coverages available:

Short Term Disability Coverage (STD)

When you’re out of work because of illness or injury for a brief period

of time (one week to six months), your short term disability beneﬁts

should provide at least part of your salary or weekly pay. Insurers

do not generally cover these costs; your employer does. That often

makes it easier to get approved for STD beneﬁts.

Applying for STD beneﬁts is the ﬁrst step in requesting long term

disability beneﬁts as well.

Long Term Disability Coverage (LTD)

If it looks like your injury or illness is going to keep you out of work

for more than six months, or even indeﬁnitely, you will need to apply

for long term disability beneﬁts. Even if everyone agrees that you

have suffered a permanent injury, you cannot apply directly for LTD

beneﬁts. LTD takes over only when you have exhausted the short term

disability payments to which you are entitled.

Catastrophic Coverage

You can apply for catastrophic coverage beneﬁts when your illness or

injury is so severe that you can no longer perform the simple routines

of daily living, such as dressing, bathing or feeding yourself. The policy

should provide someone such as a home health care worker to help

you handle these everyday tasks.

How Long

Can I Receive

D Beneﬁts?

LTD benefits will

cover some portion

of your salary for

a period of up to 24

months if you can

prove that you are

not capable

of working at your

own job. This is also

known as the own

occupation rule. If

you can prove you

are disabled past

that point — and

insurers scrutinize

this very closely —

you may qualify for

LTD benefits until

you reach age 65.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

IMPROVE YOUR

CHANCES

OF WINNING

DISABILITY

BENEFITS

To increase your chance of success in your initial application, follow

these steps:

1. Be careful and accurate when ﬁlling out forms.

Insurers often ask the same question over and over (in slightly

different ways). Consider each question carefully before you

respond, and make sure your answers are consistent throughout the

application. Do not describe your limitations in terms of absolutes

such as “always” or “never.”

2. Make sure you understand your policy.

Do you know what pre-existing conditions your policy excludes?

How your beneﬁts from your short term disability policy and long

term disability policy work together? If your disability beneﬁts will be

reduced by offsets like workers comp payments or Social Security

Disability? Read your policies to ﬁnd out.

3. Focus your application on the issues most likely to win you

beneﬁts.

Concentrate on medical and functional issues that your policy

doesn’t exclude.

4. Get your Social Security Disability application completed.

CIGNA will require that you ﬁle for SSD as well as your policy’s

disability beneﬁts, usually within a year.

5. Get your doctors prepared.

You’ll need them to ﬁll out forms and answer calls from the insurer,

so ask your physicians to be on the lookout for any correspondence

from the insurance company. Request politely that they act promptly

so you meet application deadlines. Make sure your insurance

company has the right address and phone number for your doctors.

Don’t miss

deadlines

for ﬁling

initial

claims and

appeals.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

6. Get a consistent job description.

Your ability to do your job depends on its requirements. Make sure

that your description and your employer’s description of your job

requirements match. Ask your doctor to clearly explain why, based

on that description, you cannot do the job any more.

7. Expect the insurer to use video surveillance.

CIGNA and other insurers may hire private investigators to

videotape your activities, hoping they can catch you performing

some physical activity your disability shouldn’t let you do.

Investigators don’t have the right to make an unannounced visit; you

are within your rights if you ask someone who shows up at your door

to make an appointment to talk with you.

8. Don’t go it alone.

No insurance company wants to pay out beneﬁts, but an attorney

who specializes in the complex and complicated issues of federal

ERISA law can improve your chance of success. For the best results,

retain a lawyer before you ﬁle your initial application — and if you

have to appeal, do not do it without talking to an ERISA attorney ﬁrst.

CIGNA’s

Denial Tactics

Private

Investigators:

CIGNA may hire

private investigators

to videotape your

activities, hoping

they can catch you

performing some

physical activity your

disability shouldn’t

let you do.

CIGNA’s Doctors

& Nurses: Even if

they have never

seen you or treated

you, CIGNA’s own

doctors can still

disagree with your

doctor’s diagnosis.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

PROVING YOUR DISABILITY CLAIM

The insurance company has the deck stacked in its favor when it decides whether it will approve your

disability claim. It not only deﬁnes what a disability is under your policy, but it also interprets that deﬁnition.

• Doctors and nurses from CIGNA will look at your records and make their own decisions about

your diagnosis. Even if they have never seen you or treated you, they can still disagree with your doctor’s

diagnosis.

• Insurers do not accept SSD’s disability determinations either. The rules for receiving Social Security

Disability beneﬁts are different than those for most disability plans. Insurers say that means they don’t have

to award you disability beneﬁts, even if SSD has.

• They might use vocational reviews to ﬁnd jobs that they say you can do. A vocational analyst hired

by the insurer may evaluate your residual functional capacity (RFC) based on the categories below. If the

insurer can ﬁnd you work based on your RFC, it can reduce or eliminate your disability beneﬁts.

Sedentary

lifting up to 10 pounds and sitting up to six hours a day. This is typically an ofﬁce job.

Light

occasionally lifting and carrying 10-20 pounds and standing or walking as many as six

hours a day. A security guard would ﬁt in this category.

Medium

lifting up to 50 pounds and standing or walking all day. This would include a nursing

job, for example.

Heavy

lifting up to 100 pounds;

Very heavy

lifting more than 100 pounds. Both of these ﬁnal two categories could include

construction workers.

RFC Levels

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

HOW CIGNA

DETERMINES

YOUR RFC

Your RFC category relates to the type of work that you are capable

of doing for a 40-hour work week, taking into consideration the

physical and mental effects of your disability. So how does CIGNA

decide on your RFC?

• It will consider the pain you’re experiencing.

• It looks at how the disability has impaired your mental capacity.

Can you still interact effectively with your supervisors and your

coworkers? Can you comprehend and remember directions for

doing your job? Can you carry those directions out?

• The insurer looks at your medical history and at your doctors’

observations about your capabilities. It may also gather

information from social workers and/or your family members

about what you can and cannot do.

• CIGNA will consider how the time you would need for treatment

for your disability (doctors’ appointments, therapy sessions, etc.)

would impact a normal work schedule.

• It will assess your skills to identify the kind of work that you

actually could do.

Compatible jobs and the “own occupation” standard

Insurers determine whether or not you’re entitled to LTD disability

beneﬁts in the ﬁrst 24 months by looking at your RFC and your

current occupation. If you’re a nurse who has to be on your feet all

day moving from patient room to patient room, a severe leg injury

that requires you to keep your leg elevated will preclude you from

doing your job.

But after two years (or the time period determined in your speciﬁc

policy), you have to prove that you are so disabled that you cannot

do any job that your education, background and skills qualify you to

do. If you are a nurse with an injured leg, maybe you can get a job

reviewing patients’ ﬁles or doing some other type of administrative

work that doesn’t require standing or moving around.

Fortunately, it is not up to you to ﬁnd that job. The insurer has to

come up with one that pays at least 80 percent of what you were

making before you were disabled.

If you qualify for disability beneﬁts and cannot get another job, the

insurer will usually pay you up to age 65 (retirement age).

4.3

MILLION

Cigna today

provides

disability

coverage to

4.3 million

people in the

U.S. through

more than

5,100

employer

group

policies.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

INSURERS’

CLAIM-DENYING

TACTICS

CIGNA wants to remain proﬁtable, so it will try to boost its proﬁts by

ﬁnding ways to deny claims. The company may:

• Farm your case out to several medical experts. These experts

never get the total picture of your condition, only a small portion

of it. Based on this narrow view, they may determine that your

claim isn’t valid.

• Document your activities using video and investigator

surveillance. The insurance company hopes to prove that you

are faking or exaggerating your disability by catching you doing

something you should not be able to do. It may stretch the truth,

asserting that your quick trip to the grocery store proves you can

put in a full day’s work. Claims people may not even watch the

videos themselves, but might decide to deny beneﬁts based on

investigators’ reports of what they have seen. You can demand to

see the video to check whether it has been edited, and ask the

claims person if he or she actually viewed the tape personally.

• Rely on an unreliable functional capacity exam (FCE). If the

vocational analyst does not administer the physical tests for

residual functional capacity (RFC) properly, the results will not be

valid. But the insurer may try to use this unreliable data to your

detriment, denying a valid claim.

• Accuse you of malingering (faking a disability to get out of

work and get paid) or of being non-compliant. The insurer may

try to turn down your disability claim because you are not taking

the medicine exactly as the doctor prescribed. CIGNA does not

want to hear that you cannot take the prescription because you

have had a bad reaction or because the medicine has potentially

dangerous side effects that you do not want to risk.

• Try to attribute your disability to stress. Ever had a bad day

(or a bad week or month) on a job? An insurer may talk to

your supervisor and/or co-workers to see whether you’ve had

difﬁculties with them in the past. It may try to claim that your

disability came as a result of a stressful environment and that it is

therefore not covered under your disability policy.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

CASE STUDY #2: Mercer v. Life Ins. Co. of North America, Filed in U.S. Dis-

trict Court for the Western District of Louisiana, Monroe Division, Decided May 22,

2012

Alfred Mercer, the Plaintiff, sought a summary judgment in this lawsuit for ERISA beneﬁts because he argued

that the “plan administrator abused its discretion in denying beneﬁts, since its initial and subsequent denial

decisions were not supported by substantial evidence.”

In fact, the Plaintiff showed that no one disputed the material facts of his claim, and the Court agreed that

the administrator only looked selectively at evidence and did not speak with a vocational expert about his

condition or restrictions.

The Court granted his summary motion, in part.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

HOW MUCH

WILL YOUR

DISABILITY

PAYMENTS BE?

While both STD and LTD disability beneﬁts do help out, do not count

on them completely replacing your regular wages. They usually

cover a little more than half (about 60 percent ) of what you’d receive

in your normal paycheck. People who work on commission will

receive beneﬁts based on an insurance company formula.

Special circumstances

Even if you cannot work at your regular job or own occupation,

your employer might be able to ﬁnd another position for you in the

company. If you make 20 percent less than your normal pay in this

position, you might be eligible for a partial or residual disability

beneﬁt to help make up the difference.

If you qualify for workers comp beneﬁts, retirement or retirement

disability beneﬁts, and/or beneﬁts from Social Security Disability

(SSD) or the state, CIGNA will reduce your disability check by the

amount of those other beneﬁts. These reductions are known as

offsets. The same thing happens if you win a settlement in a lawsuit.

The insurance company that provides your LTD beneﬁt does not get

off the hook entirely, however. Even if the offset payments add up to

more than what your entire disability insurance payment would be,

the insurance carrier would pay out $100 or 10 percent of what your

full beneﬁt would be under your LTD policy.

STD & LTD policies usually cover a

little more than half of what you’d

receive in your normal paycheck.

CASE STUDY #3: Amara v. Cigna Corp, Filed in U.S. District Court for the

District of Connecticut, Decided December 20, 2012

This was a class action suit ﬁled by Janice Amara together with other plaintiffs against CIGNA. The issue

considered here was whether this group of people who had been denied disability, could be considered

a class for the purposes of ﬁling suit. The Court said yes and “ordered the administrator to provide notice,

reformed the plan, enjoined the administrator to enforce the plan as reformed and denied [CIGNA’s] motion

to decertify the class.”

Critically, the Court determined that calculating damages in the case would be relatively simple and would

not involve “a complex process that would require additional hearings to resolve each individual’s case or

entail complex individual determinations.”

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

What happens if I get overpaid?

CIGNA and most other insurers expect you to apply for SSD beneﬁts when you apply for your disability

insurance beneﬁts. It is not easy to qualify for SSD, and even if you do get approved, it takes time to receive

any money, although you will eventually receive back payments from the time that you applied.

Once you begin receiving SSD checks, CIGNA will expect repayment of the money they have already sent

you.

The disability insurer generally will offer you a choice: It will withhold the amount of money that it estimates

you’ll receive from SSD, or you can pay the insurer back once you start getting these checks. Either way,

make sure you understand your policy’s offset provisions and be prepared to make repayments if necessary.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

HOW PRE-

EXISTING

CONDITIONS

COULD AFFECT

YOUR BENEFITS

Disability policies typically have a clause that excludes LTD beneﬁts

for any problem that is a result of a pre-existing condition or illness.

The exclusionary period is generally 12 months, but insurers may

look back as far as three years to see whether you’ve shown any

evidence of this condition before.

Mental health limitations

Although CIGNA may pay beneﬁts for mental health problems such

as depression or anxiety, it limits such coverage to 24 months. It

may also try to use this mental health limitation to the company’s

advantage by claiming that your disability is mental rather than

physical.

Depression is a common side effect when you have been hurt

or when you are in constant pain. If you visit a doctor for help

with that depression, the insurer may argue that your problem is

psychological rather than physical.

Some medicines, especially those prescribed for severe pain,

can have unwanted side effects that may make it hard for you to

concentrate or think clearly. The insurance company may insist that

this is a mental impairment so it can stop paying LTD beneﬁts after

24 months.

When symptoms are hard to document

Insurers like CIGNA seem to be convinced that people are out to

fool the system, so they demand hard evidence of injuries (e.g.

X-rays or MRIs). But symptoms of some illnesses — such as chronic

fatigue — are extremely difﬁcult to document in this way. So is

the mental confusion that can be caused by certain prescription

medications.

Insurance companies tend to ignore patients’ reports of such

difﬁculties and either deny claims initially or cut beneﬁts off after 24

months, claiming they are mental health issues.

Don’t be surprised if

the insurer tries to link

a problem that you

consider unrelated with

your current disability.

For Example: Suppose

your family physician

prescribed some type

of relaxant because you

were going through a

very stressful time in your

life. This was nine months

before you hurt your

back, and before you ever

felt a twinge of back pain.

Then you threw out your

back trying to lift a heavy

box, and the doctor

prescribed you the same

medicine as before, only

this time as a muscle

relaxant. The insurance

company might scrutinize

your medical records

and claim that the ﬁrst

prescription shows that

you had previous back

problems and therefore

don’t qualify for LTD.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

WHEN YOUR

CLAIM IS

DENIED: THE

CIGNA APPEAL

PROCESS

Despite your best efforts on the initial application, your CIGNA

disability beneﬁts application has been denied. This denial is NOT

the end of the road. Now you will need to navigate the CIGNA

appeals process.

Once CIGNA decides to reject your disability beneﬁts claim, it will

send you a denial letter. The company will have to explain all the

important facts about its decision.

Read the denial letter carefully to determine how you can appeal this

decision. The company will have to advise you not only of the date

by which you must ﬁle your appeal but also of the address where

you should send it.

Since CIGNA provides disability insurance only through group

policies, your appeal is handled according to regulations in the

Employee Retirement Income Security Act (ERISA).

Unfortunately, this federal law favors insurance companies rather

than the individual making the disability claim.

Under ERISA:

• Insurers do not have consider your own doctors’ opinions when

making their decisions.

• They do not face any penalties for denying a valid claim.

• You cannot sue for damages.

The best result that you can hope for in an appeal is the judge

ordering CIGNA to pay you the beneﬁts due under your policy and

perhaps your attorney’s fees as well.

Anatomy Of A

Denial Letter

• The reason for

the denial;

• The evidence it

used to make that

decision; and

• Which of its

employees

actually looked

at the evidence.

(This employee

could be a doctor,

a nurse manager

or in some cases

just a claims

representative.)

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

The ERISA Administrative Appeal Process

Unfortunately, an administrative appeal is not a swift process.

Here’s the timetable:

• CIGNA has 45 days to make its initial decision once you ﬁle a

claim. The insurer can sometimes extend that deadline up to 60

days.

• Once you appeal, the company has 45 days from the date you

submitted the paperwork to consider that appeal. That deadline

may be extended by another 45 days.

• If CIGNA denies your appeal, you will have anywhere from

several months to three years to ﬁle a lawsuit. Check your policy

for speciﬁcs.

Once you ﬁle an appeal, you cannot add any other evidence to

the record, even if you take the case to court.

Missing a deadline or neglecting to include a critical piece of

evidence can make it impossible for you to ever collect your

beneﬁts.

Because of this, ﬁling an appeal of a disability claim denial is not

something that you should tackle on your own. An experienced

ERISA attorney understands the process, and he or she will make

sure that your appeal includes all the essential documentation and

information and that all deadlines are met.

Did you know?

It can take as long

as a year before

you get the ﬁnal

word on whether

or not CIGNA

will approve your

claim this time or

once again deny it.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

Your appeal must include:

• A point-by-point rebuttal of CIGNA’s assertions in the denial

letter, backed up by the expert opinions from medical and

vocational specialists.

• A case record that clearly documents and supports your

disability claim, including medical records, physicians’ opinions,

supporting letters from your employer and from friends.

• A rebuttal of any attempt by the insurer to distort evidence and

an explanation of why the medical reviews CIGNA has presented

are incorrect in your case.

• The latest medical and scientiﬁc ﬁndings that support your

disability claim.

Your ERISA attorney will help you prepare all this and review your

policy carefully to make sure that CIGNA has followed all of the

proper procedures as it has handled your claim.

CASE STUDY #4: Williamson v. Life Ins. Co. of North America (LINA), ﬁled in

U.S. District Court for the District of Nevada, Decided March 25, 2011

Per court records, the insurance company issued a disability insurance policy to Lavon Williamson through

First Command Financial Planning, Inc. that went into effect in the beginning of 2008. At that time, Williamson

was a Direct Advisor who supervised other ﬁnancial advisors for the company. Williamson said that he

had been working as an independent contractor for the company for nearly a decade when he submitted

a disability claim in May 2009 because of debilitating pain in his neck and shoulders and accompanying

migraine headaches. LINA denied his claim, saying that his medical records did not support it. Williamson

gathered additional medical reports and documentation to no avail — the claim was still denied.

In April 2010, Williamson ﬁled a Complaint in Court against the insurer, arguing for relief due to “(1) Breach of

Contract; (2) Bad Faith; and (3) Unfair Claim Settlement Practices.” He argued that LINA treated his claim as if

it were governed by ERISA even though the insurer knew it wasn’t.

LINA ﬁled a Motion to Dismiss, which the Court denied “because an issue of fact remains regarding whether

the Plan qualiﬁes as an ERISA plan.”

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

FILING A

LAWSUIT AFTER

LOSING AN

ADMINISTRATIVE

APPEAL

Under ERISA, you must be able to prove that you followed all the

administrative steps outlined in your policy before you ﬁled your

lawsuit against the insurance company.

If your claim moves through the appeal stages and is still denied

by CIGNA, you will ﬁle your appeal in federal court, which does not

offer consumers as many protections as state courts generally do.

In a state court, you would only have to convince the judge or jury

that you really are disabled.

Remember, under ERISA law you are only allowed to sue for the

amount of the disability beneﬁts that you could get under the

terms of your policy. There is no suing for damages (punitive or

compensatory).

You must meet all ﬁling deadlines; if you do not, you will lose any

possibility of collecting your LTD beneﬁts.

Things to Know About Your Lawsuit in Federal Court

• A judge will hear your case. There are no juries in ERISA cases.

• You cannot bring in new evidence. (That is why it is so important

to make sure you have a solid, well-documented case for your

administrative appeal.)

• You will have to prove the insurance company did not have any

good reason to deny your claim, based on the evidence you

presented in your administrative appeal.

• Even if the judge rules in your favor, he/she can only award you

the beneﬁts the company should have paid from the time you

ﬁled you claim and direct that the insurer pay your monthly

beneﬁt from now on.

• A court decision in your favor does not preclude the insurance

company from trying to cut off your beneﬁts in the future, if it

decides you are no longer disabled. (Then you will have to begin

the whole appeals process over again.)

Did you know?

In federal court,

the assumption is

that the insurer

had a reasonable

basis for denying

your disability

claim, and it is up

to you to prove

that it did not.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

CHOOSING

THE RIGHT

DISABILITY

ATTORNEY

With your CIGNA LTD policy, you only get one chance to appeal a

claim denial to the company. Working with attorneys who specialize

in LTD cases will give you the best possible chance of winning that

appeal.

Experienced attorneys understand the ﬁling and appeals

procedures, and they can make sure that you meet deadlines and

present the strongest evidence to bolster your claims.

They understand the case law surrounding long term disability

denial lawsuits, as well as how to cite it before the judge.

They know how different insurance companies work, and they may

be able to negotiate a settlement for you before the case even goes

before a judge.

Choosing the right attorney is an important decision. Here are some

factors to consider in your choice:

CASE STUDY #5: Topits v. Life Ins. Co. of North America (LINA), U.S. District

Court for the District of Oregon, Portland Division, Decided April 11, 2013

Mark Topits, the Plaintiff, alleged that he was entitled to relief per ERISA, arguing that LINA discontinued

disability payments to him that were due to him per the terms of the relationship between LINA and Hawthorn

Retirement Group LLC.

Per Court records, “He asserts that he is totally disabled under the terms of the Plan due to the cumulative

effects of a stem cell transplant sequelae, including chronic graft versus host disease (“GVHD”), bronchiolitis

obliterans, and an incompletely reconstituted immune system.”

He sought damages from LINA of $978 per month for every month from May 2011 through April 2013, saying

that because he was totally disabled, he should have received those payments. He also sought attorney’s fees

and costs as well as pre- and post-judgment interest. After ﬁling a Motion for Summary Judgment, the Court

entered a judgment in favor of Topits.

Topits appeared again in court in September 2013, in part because LINA objected to Judge Stewart’s

decision. The insurer claimed he “lacked jurisdiction to conduct a bench trial on the administrative record”

and argued that “LINA properly discontinued Mr. Topits’ LTD beneﬁts.” The Court disagreed and afﬁrmed that

“Mr. Topits is entitled to LTD beneﬁts under the terms of the Plan.”

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

Make sure you work with actual lawyers.

Some so-called ERISA experts may be willing to handle your case and charge you a fee, but if they are not

attorneys, they will not be able to take your case to court if you lose the administrative appeal. You can

simplify a difﬁcult and complex process by working with an attorney from the start.

Determine the attorneys’ ERISA/disability law experience.

How many cases do they try each year, and how long have they been doing it? Do they focus a lot on this

area of the law, or do they work on diverse cases?

With so much riding on the outcome of your appeal or lawsuit, this is not the time to risk your future on

someone who is not up to speed on the latest developments in this ﬁeld.

Ask how prospective attorneys have contributed to the ﬁeld of ERISA/disability law.

Have they written papers about disability law, and can you read them? Has the legal community awarded

them any honors or distinctions in recognition of their contributions? Awards indicate the attorneys have

earned the respect of their peers.

Check social media sources.

There are many online resources that may help you get a feel for what working with a particular attorney

would be like:

• Look for reviews on Google, Yahoo and Yelp. (Consider the consensus of opinions; do not be thrown off

by one or two bad reviews.)

• Check out martindale.com, which uses anonymous peer review surveys to rate lawyers.

• Consider Avvo.com, which assigns attorneys a 1-10 rating based on their experience and the reputation

they have earned in the legal community.

• Go to Super Lawyers if you are looking for a high achiever in disability law.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

MARC

WHITEHEAD &

ASSOCIATES

WILL HELP YOU

FIGHT

You are not at your best when you’re preparing to ﬁle a disability

claim. You’re probably ﬁghting with an illness or living with pain and

may have other problems from an injury. You are also dealing with

the ﬁnancial and emotional implications of your disability.

Under these circumstances, it is difﬁcult to think clearly, act wisely

and meet deadlines. But that is exactly what you need to do to get

the disability beneﬁts you deserve under the policy that you have

paid into.

Disability law is complex and demanding. The insurers have lawyers

who specialize in looking out for their best interests (i.e. in ﬁnding

ways to save money by denying claims). Shouldn’t you have that

same kind of seasoned, aggressive help on your side during this

process?

Founding partner Marc Whitehead is a skilled and experienced

litigator with a thorough understanding of the disability insurance

industry. Our litigation practice in both private long term disability

coverage and group (ERISA) claims has earned us extensive

experience and respect in the state and federal court systems.

Our law ﬁrm was founded on the principles of skill, integrity and

professionalism, and we pride ourselves on delivering exceptional

personal service and unparalleled results in obtaining disability

beneﬁts for those who have been unfairly denied.

When CIGNA has denied your disability claim, you get only one

chance to document the reasons why this decision was wrong.

Our experienced ERISA attorneys know how to gather medical

records, physicians’ reviews and other supporting material to create

the strongest possible case for your claim.

We also invite you to download our free ebook, Disability Insurance

Policies: How to Unravel the Mystery and Prove Your Claim, for a

more detailed treatment of this subject.

Marc Whitehead

& Associates,

Attorneys at Law

is a disability law

ﬁrm based in

Houston, Texas,

that serves clients

across the nation.

Need insight into your Cigna claim?

Call Marc Whitehead & Associates, Attorneys at Law, LLP at 800.562.9830,

or learn more at www.DisabilityDenials.com.

Disability Denied By Cigna? How to Prevail When Cigna Won’t Pay

DISCLAIMER

Disclaimer for “Denied Disability by Cigna: How to Fight Back

and Prove Your Claim”

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consultation with an attorney. Requesting this book or viewing the

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MARC WHITEHEAD & ASSOCIATES LLP IS PROVIDING “Disability

Denied by Cigna? How to Prevail When Cigna Won’t Pay”

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