At Dell & Schaefer, we’ve handled thousands of disability claims against Cigna and NY Life over the years, learning some of the fine details of their disability claims approval process. For the uninitiated, showing Cigna that you’re too disabled to work can be far more difficult than it may seem. Cigna’s claim representatives often even engage in video surveillance to see if claimants are exaggerating their symptoms. Learn more about what you’ll need to document to prevent your claim for Cigna long term disability benefits from being denied, as well as some of the steps Cigna may take to guide you and your doctors toward certain responses.
GREGORY DELL: Hi. I’m Greg Dell with Attorneys Dell and Schaefer, and I’m here with attorney Rachel Alters. And we’re going to discuss Cigna claim handling. And Rachel, this is a unique service that we offer, in which we help claimants to manage their claim once they’ve been approved. And in this video, I want to talk about some tips to help a claimant prevent themselves from being denied by Cigna.
RACHEL ALTERS: Sure.
GREGORY DELL: And the first thing that comes to mind when you think about, if I was on claim would Cigna, what would I make sure I do every time to make sure I don’t get denied– what is that for you?
RACHEL ALTERS: Well, the most important thing is to treat with your doctors, because at any point when you stop treating, that gives Cigna the opportunity to cut your benefit off. So I’m very, very clear with my clients. It’s really important to make sure at least every three months you’re treating with your physicians. Even if your doctors don’t have any additional treatments for you, it’s very important that Cigna see that there’s medical records and that the documentation in the medical records reflects what’s going on with you at the time.
GREGORY DELL: Is there a magic number or minimum number of doctors that a claimant has to treat with in order to give them the best chance to stay on claim?
RACHEL ALTERS: There’s not really a minimum, but usually the insurance carriers such as Cigna will require that you’re treating with a doctor that– in the specialty of the disability that’s preventing you from working. So if you have a back injury, you can treat with many doctors. You can treat with an orthopedic. You can treat with a pain specialist. You can treat with your primary care doctor, and then maybe also a physical therapist. So depending what your condition is, I want to say the more the merrier, as long as they’re all supportive and the treatment is working for you.
GREGORY DELL: And I would highly suggest that a claim it treats with a medical doctor, as opposed to, if someone has a back condition and they only treat with a chiropractor.
RACHEL ALTERS: Right.
GREGORY DELL: I think that it’s OK to have treatment with a chiropractor, because they provide great sources of therapy as well as diagnosis, but it’s kind of like a battle the experts. I can tell you that, if it happens to be back condition– you have a chiropractor, Cigna’s expert’s not going to be a chiropractor. It’s going to be an orthopedic doctor or a physiatrist type doctor who’s going to have better credentials– which, god forbid, you get denied, is going to make it difficult.
RACHEL ALTERS: Sure.
The Amount of Medical Treatment and Having an Appropriate Medical Doctor is Essential
GREGORY DELL: A lot of people first go to their internal medicine doctor for whatever their complaint is, and then they go to a specialist, and then they might see the specialist once, and then the specialist sends them back to the internal medicine doctor. How often do you recommend those clients continue to see the specialists, even though specialists really can’t do much for them?
RACHEL ALTERS: I will recommend every three to six months to see a specialist– preferably every three, just because Cigna wants to see that– they believe that, if you stop seeing a doctor, then you’re better. Even though that’s normally not the case, that’s how they view somebody’s medical condition. So my clients can tell me, well, I’m seeing my primary care doctor. I see them every three, four months.
I saw this pain specialist, but he couldn’t do anything for me. What do I do? I tell them, if you can keep going back to the pain specialist or find another specialist that you feel can help you, it would be very valuable for your case, because Cigna is specifically looking for those kind of records.
GREGORY DELL: Rach, what do you do about the doctors who recommend some sort of pain medications, but we have a lot of clients who don’t want to take them because they’re worried about being addicted to them, they don’t like the side effects of them? And then Cigna argues, well, your pain isn’t so bad because you’re not taking the meds. What’s a claimant supposed to do in that situation?
RACHEL ALTERS: There’s a couple different things they can do. They don’t have to say they’re not taking the meds, but oftentimes, they just– they’re very vocal about it. So there’s other treatments that a claimant can do other than taking pain medication, such as Percocet or oxycodone. There’s injections they can get. There’s physical therapy that they can have. There’s other things that a claim they can do other than taking pain meds.
And the policies don’t require that they take a pain medication or have a surgery. So even if a surgery is recommended, a claimant doesn’t have to have the surgery.
GREGORY DELL: Well, that’s another good topic. Why don’t they have to have the surgery if it’s recommended?
RACHEL ALTERS: Well, there’s a lot of benefits– risks and benefits to it to an operation– any operation. So for a claimant to put themselves at risk just to stand claim– things can go wrong in a back surgery where it can fail– really bad things can go wrong in a back surgery as well, where somebody could not be able to walk after back surgery. So it’s really up to the claimant, and a policy cannot– insurance carrier cannot force a claimant to have surgery. That’s a question that I often get. And they’ll say, hey, surgery was recommended. Do I have to do it to stay on claim? And I tell them, absolutely not.
There are Traps in the Cigna and New York Life Claim Forms That You Can Avoid
GREGORY DELL: So medical support’s extremely important, and we work with the clients to help them and coach them to work with their doctors to get the appropriate support, but Cigna also has either monthly or every three month claim forms that they want completed. Talk about how you work with clients to get those completed, and the traps that you see in those claim forms on a regular basis.
RACHEL ALTERS: Sure. The claim forms will exist of a claimant questionnaire, which they’re going to ask the claimant, what are your restrictions and limitations? How long can you sit? How long can you stand? How long can you bend, stoop– all of those things? They want to get that on paper so that, if they follow you with surveillance one day, they can say, oh, well, you said you can’t lift more than 2 pounds ever, but we saw you lifting a case of water, or we saw you lifting something very heavy, and we’re going to deny your claim now.
With the attending physician statements, I often see traps with those where they’ll give the doctor some options as to what kind of work they think that the patient can do, and they’ll say, can they do you know light duty? Can they do medium duty? Can they do a sedentary job? And there’s no other option. So the doctor looks at the sedentary checkmark and says, oh, I’m going to check sedentary because that’s the least work that I think they can do– and they can’t even do a sedentary job.
So what happens oftentimes– if you’re not careful and the doctor checks that sedentary box, then they’ll deny your claim saying, well, you can do a sedentary job sitting at a desk. And the claimants and the doctors will say, well, there were no other options on the attending physician statement. So normally, what I tell the doctors to do is they make their own section– so less than sedentary. They can write that in if it’s not an option on the form. That’s often a trick I see that the insurance carriers are putting on their claim forms.
GREGORY DELL: On claimant statements, do you often do addendums for your clients?
RACHEL ALTERS: Yes.
GREGORY DELL: And why do you do them, and what are they?
RACHEL ALTERS: An addendum could be an extra notes sheet of paper that you attach. So in a space where it says, please describe your hobbies, or please describe your daily activities, or one of those things, we can say, see attached, and then we will attach an addendum, which is a paragraph or a page– depending on the situation– of describing what the activities are, what your pain is, the things you can and can’t do, because the claim forms are often only provide a line or two, and it’s not enough to express what’s really going on with the claimant at the time.
Does a Claimant Need to Be Fearful of Video Surveillance?
GREGORY DELL: Every Cigna claimant– I should say [INAUDIBLE]. It seems like every Cigna claimant who calls me who’s on claim goes, are they running video surveillance of me? Are they watching me? Are they tapping my phones? Can I go out? Can I do this? Start with the video surveillance. Should a claimant assume that they’re always under video surveillance?
RACHEL ALTERS: Yes and no. Yes– I don’t like my claimants to be paranoid and be afraid to go out of their house– however, I tell them to remember everything that they told the insurance carrier that they couldn’t do, and just keep that in the back of their mind so, when they do leave the house, not to do the things specifically they say they couldn’t do. And that’s why also it’s important to fill out the forms a certain way, and not to be so cut and dry with, I could never ever sit for two hours at a time.
Yes, they will most likely follow you with surveillance at some point, and nobody knows when. They usually catch you on a day when you’re doing something you probably shouldn’t be doing. It’s just the luck of the draw.
GREGORY DELL: Or a day where the person’s feeling good–
RACHEL ALTERS: Or they’re feeling good, and they’re out, and they decided they’re going to walk the dog for two hours– just keep it in mind. Again, I don’t want you to be neurotic about it and be afraid to leave the house, but just keep it in mind that you’ve told them that you can’t do certain things, so try not to do those things in public.
GREGORY DELL: And when you have a Cigna claimant who’s been on claim for a couple years, should they feel that they’re on autopilot now and they’re not going to have any issues? Does that matter to Cigna how long someone’s been on claim?
RACHEL ALTERS: No, absolutely not. I have people that have been unclaimed for 10 years, and for whether it’s a new adjuster that took over, or whatever the reason is, they’re suddenly revealing their whole claim, sending them for an independent medical evaluation, and following them with surveillance to look for reasons to cut them off. And this is after 10 years of being on claim.
When is the Best Time to Start Preparing for the Change of Definition for “Disability”?
GREGORY DELL: When we see a lot of claims denials, they come at this change of definition. And Cigna’s known for changing their definition of disability from inability to perform the duties of your own occupation– which is what the claimant was doing at the time that they stopped working– to unable do any gainful occupation– which, usually, in Cigna, has an income component to it, which means 60% of what you used to earn. When should a claimant start to make sure their medical records and just their entire file is set up for this change in definition, showing appropriate support so that they don’t get denied?
RACHEL ALTERS: Well, sometimes Cigna will send a letter warning the claimant and whoever represents them that this change a definition is coming. Sometimes they don’t. I usually suggest about six months before the change of definition– so about 18 months into the claim– you’re going to your physicians, explaining to them that you are going to have a definition change, which now is going to be that you can’t do any gainful occupation– which essentially means that you can’t do a sedentary job sitting at a desk 40 hours a week and make at least 60% of your previous income.
And the doctors need to know that so you know if your job beforehand required physical labor– whatever it may be– it’s no longer going to be that. And the doctors need to be specific in the medical records that you can’t sit for long periods– that it’s painful for you, or whatever other things that are causing your inability to work. And any gainful occupation has to be documented.
GREGORY DELL: When we’re representing a claimant and they’re on claim, we tell Cigna that all communications should come to our office. Nothing should go to the client– to the claimant at all. Why is that advantageous for a claimant?
RACHEL ALTERS: Oh, it’s extremely advantageous. So a lot of times, Cigna will call the client, try and catch them off guard, ask them leading questions– trick questions. And everything’s being recorded. So a lot of times claimants get denied just from a phone call from a Cigna representative. And then they badger them, they send them letters, and it causes a lot of my clients who may have a claim for a serious medical condition– most likely causes them a lot of stress and anxiety to have to deal with the insurance carriers.
And it’s a big weight lifted off of them when they know that they won’t get any more phone calls. They don’t have to respond to any other letters. They won’t be contacted unless it’s through us, and it really does make a difference.
GREGORY DELL: All right, so this is a service that we offer to claimants all over the country, no matter where they live. We’ve represented hundreds and consulted with thousands of Cigna claimants, so we’re very, very familiar with all of the Cigna long-term disability policies. Now, we know that everything we’re saying for Cigna now is going to become under the umbrella of New York Life because of the fact that New York Life recently purchased Cigna in a $6 billion transaction.
But we anticipate that things should stay the same because of the fact that New York Life didn’t really have a group disability division, whereas Cigna’s been one of the largest group disability providers in the entire country. So we don’t expect a big change there, but you may start to get correspondence from New York Life and wonder why we were talking about Cigna so much during this video.
So the first steps to work with us is simply send us a copy of your disability policy. We may want to see a copy of your application for benefits so that we can get a good understanding as to what your claim has been about. We’ll immediately set a free phone consultation. You have the option to give us a call now or submit a free email consultation through our website, which one of our lawyers will respond to you right away. We’ll set an appointment, we’ll go through everything for you relatively quickly, and we’ll let you know immediately whether or not we can assist you.
Dealing with a disability insurance carrier can be a full-time job in itself – and a stressful one at that. By partnering with a disability insurance attorney like the team at Dell & Schaefer, you’ll be able to stop these calls from coming to you and instead allow our team of legal experts to negotiate the claim with Cigna / NY Life on your behalf. If you’re ready to gain an experienced partner in your journey toward disability benefits, get in touch with us today to schedule a FREE consultation with one of our long term disability attorneys.