Tuesday, January 21, 2014

CIGNA Reverses STD & LTD Decisions

I represent a former Senior Director of Program Management (“SDPM”) whose microvascular ischemia forced him to stop working when he was 62 years old. I was retained after CIGNA denied applications for short and long term disability benefits. CIGNA contended that the claimant had the ability to work as a SDPM because he could perform its physical demands. CIGNA had disregarded the fact that the treating cardiologist advised the claimant to stop working to avoid the effect that work stress had on the microvascular ischemia. 

The issue that CIGNA failed to recognize is that in this type of situation, risk to health trumps ability to perform work. Courts have refused to allow administrators to deny benefits for future risk when such a denial would put claimants or others at risk, unless the policy at issue expressly denies coverage of such future risks. When assessing whether a future risk of harm or relapse constitutes a disability, the question is the probability of its future occurrence. 

I secured a report from the treating cardiologist specifically explaining the substantial risk that continued work as an SDPM posed, including the family history of death from heart disease. I pointed out that CIGNA’s Policy does not exclude risk of future harm. To pre-empt an attempt to limit liability under a 24 month benefit cap for mental conditions, I cited case law where courts held that the stress resulting from the microvascular ischemia constituted a cardiological problem, not a psychological one.

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