Cigna Tag Archives — California Insurance Lawyer Blog

January 31, 2020

What ERISA Rights Do I Have After I Appeal My Denied Long-term Disability Claim?

Over the past 15 years, I have represented hundreds of claimants in their claims for disability benefits governed by the Employee Retirement Income Security Act of 1974, also known as ERISA. If an ERISA disability claim is denied, a claimant must appeal that denial to the plan administrator or insurance company before he or she is able to file a lawsuit. The appeals process is referred to as exhausting administrative remedies (though there is no administrative agency involved). The ERISA Regulations provide rules that an administrator must follow in order to give a claimant a “full and fair review.” See ERISA § 503; 29 CFR § 2560.503-1 (Claims procedure).

Effective April 1, 2018, the ERISA Regulations were changed to require that an insurance company or administrator provide to the claimant copies of new evidence it obtains after a claimant submits an appeal so that the claimant has an opportunity to respond to the new evidence before the insurance company issues a final claim decision. Some insurance companies, however, refuse to provide this evidence to claimants who filed their disability claims before April 1, 2018.

What if you fall into this pre-April 1, 2018 category? Do you have any rights to know what the insurance company is relying on before it issues a final decision on your appeal?

July 18, 2019

Kantor & Kantor Wins Long Term Disability Benefits for Claimant Disabled by Trigeminal Neuralgia

by Monica Lienke

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.

May 15, 2019

Is Cigna Living Up To Its Commitments?

by Kantor & Kantor LLP

Long term disability policies frequently have two different definitions for disability. The first provides benefits if one is unable to perform their “own occupation.” To determine benefits under these criteria, the carrier often looks at the “material and substantial duties” of the insured’s occupation and whether the insured can perform those duties with his or her restrictions and limitations.

After 24 months, the criteria often change to whether the insured can perform “any occupation” for which he or she is suited by education, training and experience. Most, but not all policies, also expressly include “station in life” criteria. This means the carrier must also consider the insured’s prior earnings and any alternate occupation identified by the carrier must pay earnings commensurate to the insured’s prior occupation.

We frequently see carriers terminate benefits at the “any occupation” phase of the Plan based on mythical occupations. For example, Hartford has terminated benefits for our clients, stating that the insured can be a “Lens Inserter” or a “Jacket Preparer.” The carriers take the position that it does not matter if the job actually exists in the national economy. Since the occupations are identified by the outdated Dictionary of Occupational Titles, the carriers believe that they are suitable alternative occupations.

April 3, 2019

The Likes of Sedgwick, Reed Group, Cigna, or Aetna Can Have a Conflict of Interest When Acting as a Third-Party ERISA Claims Administrator

by Kantor & Kantor LLP

Many large companies offer employees “self-insured” or “self-funded” ERISA plans to provide disability insurance or health insurance benefits. However, these companies are not in the business of administering health or disability claims. This makes sense. Boeing doesn’t know how to evaluate a short term disability claim. Intel isn’t in the long term disability business. AT&T doesn’t know how to read medical billing codes. So, instead of trying to do this itself, most companies hire other companies to administer the disability or health insurance claims.

These “third-party” companies are either in the business of administering ERISA benefit plans (e.g. Sedgwick and Reed Group) or are already administering these types of claims because they offer medical or disability insurance themselves (e.g. Cigna and Aetna). In theory, a benefit of this structure is that the entity making the claims decision is not the same entity that has to pay the claim. There is no structural conflict of interest.

How do courts view this type of structure if a lawsuit is filed? In such a situation there was a denial of disability benefits or a medical claim was denied. If the ERISA Plan conferred discretionary authority to the claim administrator – and almost all do this – the court reviews the denial of benefits under the plan for an abuse of discretion. Firestone Tire & Rubber Co. v. Brunch, 489 U.S. 101, 115 (1989). Once the court determines that the insurance policy unambiguously grants discretion to the entity that denied the claim – here the third party administrator – the court must determine whether the administrator or fiduciary was operating under a conflict of interest. Metropolitan Life Ins. Co. (MetLife) v. Glenn, 554 U.S. 105 (2008) (“Often the entity that administers the plan, such as an employer or an insurance company, both determines whether an employee is eligible for benefits and pays benefits out of its own pocket. We here decide that this dual role creates a conflict of interest; that a reviewing court should consider that conflict as a factor in determining whether the plan administrator abused its discretion in denying benefits; and that the significance of the factor will depend upon the circumstances of the particular case.”); Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 965 (9th Cir. 2006) (“Abuse of discretion review applies to a discretion-granting plan even if the administrator has a conflict of interest. But Firestone also makes clear that the existence of a conflict of interest is relevant to how a court conducts abuse of discretion review.”).

May 12, 2017

Just Because An Insurance Company Denies Your Life, Disability or Health Insurance Claim, DOES NOT MEAN YOU SHOULD GIVE UP!

by Kantor & Kantor LLP

For over 25 years, I have been representing individuals who have had life, health, and disability claims denied by their insurance companies. I have represented over 3,000 people. What is so disheartening to me is that I hear from clients again and again that they “almost gave up before calling” me. They tell me they were beaten down by the process, convinced their insurance company must be right, or that they didn’t know there were lawyers who specialized in handling their kind of case on a contingent basis. While sometimes the client HAS waited too long for us to help them, usually my law firm, Kantor & Kantor, is able to step in and successfully resolve their claim.

However, I wonder just how many DO give up unnecessarily. While my view of the insurance industry may appear very cynical, I am 100% convinced that the industry employs a strategy of denying as many claims as possible in the hope that claimants will just give up and go away. I could write pages upon pages of stories about clients who had almost given up, but for whom we were able to obtain benefits with nothing more than a well written letter. It sometimes seems like the insurance company is daring their insured to challenge the denial, or to get a lawyer. If they do, the insurance company will reconsider its denial. If not, the denial will stand and the insurance company will keep the benefits which are rightfully yours.

In the last month, I have obtained over a $1,000,000 in total benefits for several clients who separately told me that they had seriously considered giving up before calling my firm. This led to me to come back to a familiar thought, which was to wonder about all the people who did simply give up. I decided to write this blog in the hope that maybe ONE insured might read it, and decide not to give up. I am not writing this to get business. I have more than I need. I practice in California, but this blog might be read by someone in Florida, or Illinois, or New Jersey, for example. If it is, and you were considering giving up trying to get your benefits, I am not suggesting you call me. Go on the internet, or call your State Bar, and find an experienced attorney in your State. The worst thing that happens, is that no one will take your case — but what if they will?