Kantor & Kantor won a notable victory against the Life Insurance Company of North America (also known as “LINA” or “Cigna”) in Elliott v. Life Insurance Company of North America, Inc., No. 16-CV-01348-MMC, 2019 WL 2970843 (N.D. Cal. July 9, 2019), a case in the San Francisco Bay Area involving a denial of long-term disability benefits to the plaintiff who is disabled by trigeminal neuralgia.
The plaintiff, Elliott had to stop working in his position as Vice President of a brokerage firm due to symptoms from trigeminal neuralgia, a chronic pain condition affecting the trigeminal nerve, which is a cranial nerve responsible for sensation and certain motor functions in the face. Elliott was experiencing symptoms including shooting facial and head pain on a daily basis, migraines, difficulty talking, as well as medication side effects including sedation and cognitive slowing.
LINA had approved Elliott’s initial claim for short-term-disability, but denied his claim for long-term disability benefits and upheld its denial on appeal, stating that there was a lack of objective evidence to support his diagnosis. After the Social Security Administration approved Elliott’s social security benefits claim, finding him disabled, LINA had another opportunity to reconsider its decision deny Elliott’s claim but declined to do so.
In deciding the case, the court applied the de novo standard of review under F.R.C.P. 52, considering both the legal and factual aspects of the claim anew, and found that Elliott was disabled under the terms of his policy. The court’s analysis began by considering the evidence and determining that Elliott did have a “sickness” as required by his policy, specifically trigeminal neuralgia. The court then went on to determine that as a result of trigeminal neuralgia, Elliott was unable to perform the material duties of his own job (his “Regular Occupation”), satisfying the policy definition of disability.
The decision in this case covered what might be called the “best hits” of many common theories and arguments in ERISA long term disability cases:
- LINA based its denial on lack of “objective evidence,” however, a lack of objective evidence is not relevant where the policy does not limit the scope of covered conditions to illnesses that can be documented objectively (this is important where trigeminal neuralgia can sometimes be traced to a physiological abnormality but it is frequently a diagnosis of exclusion);
- the observations and findings of treating doctors, the State of California (EDD), and the Social Security Administration are not binding but they constitute evidence that a claimant is unable to work;
- a claimant’s treating physician has a greater opportunity to assess credibility than a plan administrator’s reviewing physician;
- further supporting credibility is the fact that Elliott’s type and frequency of pain is consistent with the medical literature’s descriptions of symptoms usually experienced by patients with the condition;
- Elliott’s history of consistent employment supports the finding that the cessation of work was due to an inability to perform job duties rater than a lack of motivation;
- further supporting Elliott’s credibility was the insurance company’s finding that Elliott was entitled to short-term disability benefits and there was no showing of improvement in his condition;
- the fact that Elliott declined to undergo intensive and risky brain surgery was not indicative of a lack of credibility.
The court found that our client’s job as a Vice President was “very cognitively demanding” and that he was unable to perform his job due to his pain and medication side effects. The court remanded the issue of whether Elliott is entitled to “any occupation” benefits to LINA.
Kantor & Kantor has helped many clients with claims against Cigna. If you have a denied long-term disability claim, contact us for a free case evaluation by calling 877 783 8686 or using our ONLINE FORM.