Long Term Disability Law BlogAttorneys Helping Disabled Claimants Nationwide

What New York Life/Cigna Disability Claimants Should Know About Claim Denial

At Dell & Schaefer, our experienced nationwide network of attorneys has extensive experience in handling New York Life/Cigna disability insurance claims, and we’ve noticed that these claims tend to follow one of two paths. If an applicant has a detailed, comprehensive medical history that clearly documents that their disabling condition arose¬†after¬†they began coverage under a New York Life/Cigna disability insurance policy, the claim may be approved. But in most other cases, where there may be some evidence a medical condition existed before disability coverage kicked in, or the applicant’s medical records contain gaps or unanswered questions, Cigna may deny the claim out of hand. Learn more about the most common reasons Cigna cites for disability claim denial, as well as how applicants can overcome them.

GREGORY DELL: Hi, I’m attorney Gregory Dell, I’m here with attorney Steven Jessup. And we’re going to talk about one of the most important aspects of any disability claim, which is the applying for disability benefits. And this video is going to feature on applying for long-term or short-term disability benefits with Cigna Disability Insurance Company.

Now, Steve, also, this video is going to be about applying for benefits with New York Life, because just a few months ago, it was announced that New York Life is acquiring the disability division of Cigna Insurance Company in a $6 billion plus purchase. So we’re going to see more claims than Cigna already had, and we think the Cigna people are going to continue to manage the claims because of the fact that New York Life really didn’t do much group work at all. But as of right now, we don’t have any information to share about how it’s going to change, if at all. But it really shouldn’t change much about how we’re going to say that a person should go about applying for benefits, and what’s important.

Now we’ve helped probably thousands of Cigna claimants to apply for a long-term disability benefits. I want you to go about– we’re going to go through steps about the important things and things that a claimant should know when applying but, what’s the first thing– excuse me– the first thing that you look into when a Cigna claimant comes to you.

Always be Aware of the Pre-existing Condition Provision to Prevent a Claim Denial

STEPHEN JESSUP: I mean, the absolute first thing you have to look into is is they’re going to be an issue with a preexisting condition? Most of these policies, especially long-term– short-term disability policies don’t often have preexisting conditions, and if they do they’re– you only have to be employed for seven days often. So it’s not much of an issue.

The bigger concern is the long-term. And as a standard language that they’ll have is if you file a claim within 12 months of coverage under the policy, not necessarily employment, because you may have to wait three months before you’re eligible to be enrolled– 12 months of coverage. If you file a claim for disability prior to that, that means Cigna is going to go back and they’re going to take a look at usually the three month period prior to disability. And if you had treatment for the condition you’re claiming as a disability, then they’re going to deny for a preexisting condition.

And a lot of times, people say, well, you know, I’ve been employed with them and I’ve been covered under the policy for like 14, 15 months. But it’s not that while you’re on disability, you’re not accruing that time. It’s while you’re working and covered in there.

So one of the first things we usually inquire is how long have you been employed with the company, and then how long have you had benefits– just to make sure they’re not going to have an easy road to denial. Because there are ways to get around preexisting conditions if you can wait out the process a bit. So that’s always going to be number one for me.

GREGORY DELL: So have you had clients call you during that preexisting period and have you been able to assist them to get approved.

STEPHEN JESSUP: If they’ve already won out on disability and they’re not going back, or whatever the case may be. It’s going to be very, very tough. Now, in situations where people start like a short term claim, and then they contact us and we discuss and they bring up the preexisting condition, sometimes they transition back to work. So then they’re able to accumulate back into that 12 months of coverage and then look at filing at a later time again. But if you fall within the parameters of that preexisting condition, it’s very, very, very difficult to get around that– barring being able to say, well, there’s a new medical condition that’s not related in any way.

And this so you know, it isn’t the exact diagnosis. Say you know, a doctor thinks you have one thing wrong with your back, for instance. So that’s what they’re running on, but it turns out it’s something completely else. If it’s all related and the diagnosis is hashed out later, Cigna is still going to look at it in the context of a preexisting condition.

Medical Support is Essential for a Cigna / NY Life Disability Benefit Approval

GREGORY DELL: OK. The second most important thing is the medical information. How does a claimant and go about reaching the point where you think they have the appropriate medical documentation and why is the medical documentation so important in applying for benefits with Cigna?

STEPHEN JESSUP: You know, starting with the first one– why it’s so important? Your claim is can be based on the medical information. If you haven’t been to the doctor, if the doctor’s not taking good notes– you’re not going to get approved. It’s really that simple.

So when we look at the medical records leading up to it, you want to see that there’s discussions with the doctors, that there’s been problems, that you know, whatever the situation that you have that’s causing you on disability, how it’s affecting your ability to work and that your doctor is documenting that. Because Cigna first and foremost is going to look at those records.

Surprisingly, a lot of people contact us and they’ve made application for benefits and they filed for disability before I ever even seeing a doctor. That’s a problem, because at the time of disability, they’re always going to want to know what’s going in contemporaneous there. If there’s no medical information to support why do you go out that day, Cigna is certainly going to look to try to deny that case.

So your medical information, the way it’s documented, and your actual just going to get the treatment is crucial. This becomes a problem in situations where you may need to see a specialist, especially for mental health conditions. Sometimes, it can be a while to get into a psychiatrist or a therapist, so you’re relying on a primary care physician who maybe be you assisting you until you can get into those specialists. But you can expect that Cigna is going to also look at that and raise an eyebrow and question how bad it must be you know, if you’re not even treating with a specialist.

GREGORY DELL: What kind of information is Cigna going to ask for when a claimant submits their long-term disability claim?

STEPHEN JESSUP: They’re going to want to know any doctors that you’ve treated with, so any names of any medical doctors. They’re going to want to know employment information. They’ll get some of that from the employer, such as you know, job descriptions, compensation. But the big thing is is why you’re filing– so what the medical condition is, and the names and contact information of your doctors is where they’re really going to start looking at first.

Tips for Completing the Cigna / NY Life Disability Claim Forms

GREGORY DELL: All right, the claim forms that Cigna is going to require– when you’re filling those out on behalf of a claimant, what’s unique that you do versus what Cigna is going to ask a claimant ordinarily who’s not represented and doesn’t know any better?

STEPHEN JESSUP: In those claim forms, you get usually one line to explain your medical condition, how it’s impacting your ability to work. There’s just absolutely no way to convey that information, so we’d like to work with our clients to do attachments and addendums where we can expand upon that, add additional information. If the claim form asks about occupational duties you can’t perform, well, same thing.

We’re going to do another addendum to it and it’s going to list everything that goes on with it. You want to present as much information as possible, because if it’s lacking, they’re going to use that against you. Same thing when looking at your medical records. If something’s not stated, they’re going to assume it’s not an issue or it’s not a problem or it’s not of concern. So we usually work with our clients to really kind of hone in what the heart of the matter is.

And also, in these claim forms, there’s going to be a lot of stuff that’s not going to be applicable to you, or that really, it’s not pertinent to what you’re experiencing, what your medical condition is. Because they’re going to send you generic claim forms, regardless of what the medical condition is, to get at least an initial understanding.

And then typically, lately, Cigna is bigger on doing follow-up phone calls with the client after they have the claim forms. And in there, in my opinion, what they’re looking for, they want to say that they’re trying to get to know the person better and little more hands-on. But they’re also starting to look for inconsistencies between what you’re reporting and what you’re saying now.

GREGORY DELL: So one of the most challenging things for a claimant is they get this attending physician statement, which is another required form. And the claimants, you know, say, OK, I’m going to go to my doctor. And then the doctors get it, and the doctors really aren’t great at filling these out. How important is that attending physician statement and how do you work with the claimant to make sure it’s filled out in the best manner possible to give a claimant the best chance to get their benefits approved?

STEPHEN JESSUP: Where the attending physician statement really becomes important, like we’ve discussed in multiple times, this idea that medical records aren’t always documented properly. They’re not as good as they could be. Because doctors are treating a patient, they’re not they’re treating a file for an insurance company to take a look at. They are notes for the doctor to help treat the patient.

So the attending physician statement will then present the opportunity to really expand upon the issues that the patient’s having. The problem with these forms is that they’re made in such a way to pigeonhole a doctor’s opinion. They don’t give room to expand upon opinions and thoughts. For instance, if you have a physical medical condition, they may say, all right, physically speaking, can they do sedentary, light, medium, or heavy work? Well, sedentary is the lowest. And those restrictions, if you can only do sedentary work– those are severe restrictions.

But since the vast majority of jobs now fall within sedentary, a doctor looks at that and they’re thinking, well, you know, that’s the worst I can do. They check that box. You know, they send it in. The problem is is that unknowing to them, they’re asserting that the client– the patient can work, instead of having room to be able to say, no, I don’t think they can do this. Or technically, they do have for below sedentary definitions, for physical ability, they don’t give the doctors the opportunity. So they almost funnel the doctors opinions into ways that will allow MetLife to argue that they can work.

GREGORY DELL: And Steve, if the claimant’s treating with multiple doctors, how many of those physician statements does the claimant need to return to the carrier?

STEPHEN JESSUP: These– when it comes to the forms to return the carrier, you want to focus on the doctors that are treating you for conditions that are affecting your work. You know, people– we have clients that treat with a dozen different doctors, maybe an eye doctor, there maybe you know, OB-GYN, certain things that aren’t necessarily pertinent to the medical condition that’s preventing.

So you kind of want to stay away from that, because if those people start filling out forms– or say your primary care physician doesn’t necessarily want to get involved, and they start filling out forms that aren’t beneficial to you– when we get denial letters sometimes I’m like, wow, this person has no support whatsoever. And then when I speak to them, I’m like, well, who’s this doctor? Who’s that doctor? I found out they are doctors that they maybe saw once, or you know, that aren’t treating them for their condition. So you want to focus on the doctors you have the relationship with, that is willing to assist you, go to bat for you, and that is treating you for a condition that is the impetus for going out on disability.

How to Prepare Your Doctor for a Phone Call from a Cigna / NY Life Doctor

GREGORY DELL: OK, now Cigna is known for reaching out to claimants treating doctors. How does a claimant prepare their doctor for that phone call?

STEPHEN JESSUP: That’s tough. I think that’s a real awkward situation for a claimant on their own to do, because a lot of times, people context, they’re like, how do I speak to my doctor? I’m afraid that you know they’re just going to think that this is all I want from them. So on your own, it is difficult.

From a perspective, if you’re represented, it’s easier because we act as insulation between that. Your best bet would be, you know, letting the doctor know you have a claim for disability, you know, an understanding of the policy that you know, can you do your job, whatever the case may be? It’s not this idea that you’re incapable of activities of daily living, and asking that, hey, if the insurance companies doctors try to contact you, you know, please wait on taking the call until you’ve at least had a chance to speak to me or if you have a lawyer involved, you can speak to my lawyer, so the lawyer can kind of give the doctor an understanding of what the insurer, what Cigna is going to be looking for, what to expect.

And I always like to– I had a phone conversation with a client’s doctor this morning– a lot of doctors don’t like insurance companies for various reasons and they don’t want to get involved. I let them know, you know, these are employer-provided policies governed by ERISA, so if we do find ourselves in court, the defense, you know, Cigna’s attorneys will not depose you, you’re not going to be called to testify at trial. It’s not going to impact your practice, your life. You don’t have to worry about a defense attorney trying to belittle your opinion.

A judge would only consider your written opinions and your medical records in these forms, the conversations that I have. So I think that also makes doctors feel more confident to support the patient. And if, given the opportunity, you’ve got to be careful, you’ve discussed this plenty of times, if they speak with Cigna’s doctors and Cigna’s doctors will send them a form saying, hey, we discussed X, Y, and Z. If you don’t agree, you know, please explain why. They even use this reverse negative. So the doctors need to be very careful that what was discussed is being represented properly before signing anything or responding.

GREGORY DELL: There’s lots of tools that Cigna uses and what we call tricks to try to say well, there’s not enough information, hence, we’re going to deny the claim. And a lot of times, it’s just a breakdown in communication. And those things can easily be avoided if your claim is protected.

So in terms of our law firm representing you on a monthly basis, it’s something that we offer as a flat-fee service that we’re happy to discuss with you. The starting point, though, is for us to provide you with an initial free consultation. And the only thing we need for that is a copy of your long-term disability policy. And we’ll set up free phone call, no matter where you live in the country, whether you speak with myself, Steve, or any of our attorneys, we’re going to be able to represent you. We always offer a free consultation, and we look forward to the opportunity to speak with you.

Navigating the disability application process can be a challenge, and as one of the largest disability insurers in the country, Cigna’s claims approval (and denial) process can seem to run like a well-oiled machine. Disability claimants who seek legal advice during this process can reduce the risk that their claim will be rejected out of hand, ensuring they receive needed benefits sooner. If you’d like some help with your application for Cigna long term disability benefits, get in touch with Dell & Schaefer today to set up your FREE consultation.

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