CIGNA, also known as Life Insurance Company of North America, has tried to market itself as a trusted insurance company. It hires advertising agencies and brand consultants to come up with new ways to get that message across to the general public.
However, like every other insurance company, CIGNA operates in a manner that furthers its own financial interests. The businesses that use CIGNA for insurance coverage do not suffer all that much when the insurance company denies a disability claim. Instead, it is the disabled employee who pays the price.
CIGNA Has the Power to Slow or Deny Your Claim
While CIGNA has some power over the process, and they can certainly make your life tougher, they are not the judge and the jury. Instead, they are more like a gatekeeper for your legal rights. They do not have the last word over whether you can receive compensation. You have the right and ability to challenge them when they have denied your claim. First, you need legal help to present your case in the most persuasive terms.
CIGNA is an insurance giant that sells health and disability insurance policies. What constitutes a good year for CIGNA may constitute many bad years for people who count on long-term disability benefits after they file their claims. Instead, CIGNA may deny claims, forcing people who need the money to have to fight to get anything.
CIGNA Makes More Money When They Do Not Pay Claims
CIGNA’s formula is a large cash cow and moneymaker. The company takes in billions and billions of dollars in premiums every year. CIGNA will invest these premiums in the stock and bond markets. They may have to pay out claims as required by insurance coverage contracts. When this happens, CIGNA has to take money out of its investments. The company does not want to do this. It makes too much money, especially in a strong stock market.
CIGNA has every incentive to delay your claim as much as possible. They may even try to deny it if they can. This way, they can keep the premiums that they earn invested and making money. However, when you have a contract that entitles you to coverage, CIGNA cannot simply do whatever they want in their own best interests.
Even though CIGNA promises protection for people who can’t work, the reality is far different when you try to submit a claim. Then, you will find that the insurance company throws up every roadblock that it can. You may find yourself dealing with more requests for paperwork and countless questions from the insurance company that wants to know more about your condition.
ERISA Gives You Some Protections in a Process that Still Favors CIGNA
As a claimant, you have legal rights under a law called the Employee Retirement Investment Security Act (ERISA). While the title of this law invokes retirement, the statute is far broader. It governs many of the employee benefits that you receive from your job. If your company has a long-term disability policy, ERISA and its many provisions will govern the policy.
While ERISA’s provisions are not exactly the most employee-friendly, they do give you rights. Unfortunately, the law gives an incentive to insurance companies like Aetna to deny claims. Insurance companies cannot face lawsuits for denying claims in bad faith under ERISA like they can for other types of insurance claims. However, you do have legal recourse when they fail to follow the regulations under ERISA.
Why CIGNA May Deny Your Long Term Disability Benefits Claim
Aetna may deny your claim because:
- They do not think that your disability meets the plan’s definition of disability
- They do not believe that the medical evidence supports your claims of disability
- They do not believe that you are unable to work
- Your claim may not have enough documentation to support your claim
- Your claim may have failed to meet a deadline or provide a required piece of paperwork.
One of the main reasons why CIGNA may hold up your claim is the lack of objective evidence. These days, CIGNA trusts your own doctor’s opinion less and less.
They want to see tests that their own doctors can read, such as:
- CT scans
- Blood panels
- PET scans
The difficulty for you as a claimant is that some conditions are subjective by nature. The pain or depression that a patient is feeling does not always show up on an MRI. Aetna can use this to make your life far more difficult.
CIGNA’s Claims Review Process Is Less Than Objective
CIGNA’s own internal review process for disability claims does not focus on objectivity. They often use in-house medical resources to review claims. One can imagine that these reviewers will not be in good standing with their bosses if they approved too many disability claims. Even vocational reports can come from a company affiliated with CIGNA. The doctors that CIGNA often uses are dependent on the company for large parts of their living. These are not exactly the type of people that you can count on to be objective.
CIGNA may want to ask you to see an independent doctor of their choosing, and you will have an obligation to make this visit. Otherwise, your benefits can be at risk.
All CIGNA needs is a colorable reason to deny your claim. It costs them nothing to throw up a roadblock wherever they can. This makes your life far more difficult, but that does not matter to an insurance company.
How the Appeals Process Works Under ERISA
ERISA gives you the right to appeal when CIGNA denies your claim. However, this appeal process is different from other legal cases. If you receive a claim denial, you need to hire an ERISA attorney immediately if you do not already have one. The stakes are too high to try to handle this critical matter on your own. If you make a mistake in the administrative appeals, it will have long-term consequences.
The first thing that your lawyer may try to do is have a conversation with the insurance company. Legislators recently changed ERISA regulations to make the process much more transparent. Now, CIGNA must be very clear about the reasons for your claim denial. It must provide you with the exact reason for the denial and must also give you copies of all documents that the adjuster used in reaching their decision about your claim. You should always know exactly why your claim was not successful out of the gate.
Talking to CIGNA can help clarify any misunderstandings that may have caused your claim to be denied. This is, of course, if the insurance company is open to listening. Sometimes, there are minor issues that can stand in the way of benefits that may not take a full-fledged process to resolve. This is the best-case scenario if you are facing a denial.
The actual appeals process does not seem favorable to claimants on the surface, especially since you cannot take your case right to court. Instead, the first level of appeal is with CIGNA itself. You may wonder how the same company that denied your claim in the first place can perform an objective review of your appeal. That is a very valid question.
However, an insurance company must handle the appeal under ERISA’s rules, and they can face a lawsuit if they do not. CIGNA is supposed to assign a different employee to decide the appeal than the one who denied the claim in the first place. They have tight timelines to decide your appeal, with a 180-day deadline to issue their decision. If they need an extension, they must present a clear reason.
You Must Take the Appeals Process Seriously at All Stages
In addition, you have every reason to take this process seriously. If not, it can limit your future options. You will build a record for the decision-maker to consider. This can include medical evidence and testimony that will establish your entitlement to this money. You must make every effort to get as strong of a case as possible in front of CIGNA, even if you do not trust their objectivity. The reason is that the record that you build for an appeal will be the one that the court considers in the future.
You hope that CIGNA lives up to its word and performs an extensive review of the prior decision. That does not always happen. If the insurance denies your claim, you still have legal options. In other words, the claims process does not begin and end with CIGNA.
Appealing to the Federal Courts
Since ERISA is a federal law, the next place to take your appeal is to federal district court. However, this may not be as robust of a process as you might have thought. If you expected your case to consist of a hearing and witness testimony in front of a judge, that will not happen.
The judge is going to look at the record that the insurance company considered when deciding your appeal. The judge may ask for new evidence in limited circumstances, but the presumption is that the record that you built for the insurance company appeal is locked down. The judge will take a fresh look at your claim and make their own decision, giving no deference to CIGNA’s original decision.
If the district court judge does not rule in your favor, you can go to a federal appeals court. In this appeal, the court will be reviewing your claim to see if the judge made an error in ruling against you, as opposed to taking a new look of their own. This is a higher standard to overturn the district court judge’s ruling, although it is possible to persuade an appeals court.
The ERISA long-term disability process often works in favor of CIGNA. However, it does not act in complete exclusion of your legal rights. CIGNA is more likely to take your claim seriously if they see that you have an experienced attorney on your side. They may be less inclined to try to get in the way, knowing that it can lead to the appeals process. If you appealed, you need an ERISA attorney to help you get things right. Otherwise, you may have to present an incomplete record when you finally get an objective and neutral judge to look at your case.
How an Attorney Can Help You With an Aetna Disability Claim
For your CIGNA disability claim, you are better off strategizing and working ahead of time with an attorney to have the best chances of success.
An attorney can do the following in your case:
- Assist you in claim preparation
- Strategizing with you about the best way to present your claim
- Handle all communications with the insurance company
- Defend their clients when CIGNA uses aggressive tactics in the claims process to make life more difficult
- Help appeal if you receive a claim denial
- Take your case to court if CIGNA denies your appeal
- File a lawsuit against Aetna if they failed to follow ERISA rules for how they handle your claim
The disability claims process is not something that you can leave to chance. Your benefits mean everything to you, and receiving them will dictate whether you can pay your bills. At the same time, you are up against a large and sophisticated company like CIGNA. Given their motivations, it really can become an adversarial process because CIGNA really does not want to pay your claim if they have a way out of it.
The average person may lack the ability to deal with CIGNA’s bureaucracy and legal apparatus on their own. With an attorney, you have the power to stand up to CIGNA and exercise your legal rights to appeal. What CIGNA says is not necessarily what goes.
Should you have any further questions, don’t hesitate to reach out to a group long-term disability insurance lawyer to get answers.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts