Our paper-reviewing doctor has determined that you’re not in pain.
Anthony Anatra vs. Long Term Disability Plan of Lumileds Lighting (CIGNA) C 05-02288 RS
Mr. Anatra was a Product Support Supervisor of Stockroom and Shipping & Receiving for Lumileds. Based on his job description alone, it was patently obvious that his position was both mentally and physically demanding. He had a medical history of degenerative disk disease that resulted in three lumbar laminectomies and one cervical laminectomy. Then he developed Graves’ disease, for which he was treated with nuclear medicine. After that, he reported feeling chronically fatigued, even after hormone therapy. He began having widespread pain and difficulty working. He consulted a rheumatologist, who diagnosed fibromyalgia. He then saw a second rheumatologist, who rendered the same diagnosis, utilizing ACR “trigger point” criteria.
Because of Mr. Anatra’s debilitating pain of the cervical and lumbar spine and joints, it got to a point where he could no longer work. His LTD plan provided benefits for six months, if he was unable to perform the material duties of (his) Regular Occupation or a Qualified Alternative" (the "Own Occupation" or "Own Occ." definition). After the first six months, the definition of “disability” changed to: "Unable to perform all the material duties of any occupation for which you are, or may reasonably become, qualified based on education, training or experience." (the "Any Occupation" or "Any Occ." definition). All three of his treating physicians agreed that he was totally disabled from performing any occupation.
Mr. Anatra submitted a timely claim for Long Term Disability benefits. His ERISA-governed claim was denied on the stated ground that there were "no medically supported functional limitations (or) restrictions supporting (a disabling) impairment”. He submitted a “voluntary” appeal of the denial before I got involved in the case. In support of his appeal, he submitted 18 categories of documents and then some other supplemental information after that.
His appeal was shrugged off by CIGNA. A claim file entry stated that the documents submitted with the appeal provided no "new information" to support the claim and did "not support a current diagnosis of fibromyalgia". This conclusion was based on two paper reviews by two in-house CIGNA physicians, Drs. Mendez and Cole, who reported that treating physicians’ findings were not supported by objective measures of his restrictions and limitations. Mr. Anatra then received a letter from CIGNA, "reaffirming" its previous denial. The letter stated that the information reviewed did "not document significant decreased functionality"; "clinical does not support functional deficits that would preclude claimant from performing essential job functions for the time period in question."
Notwithstanding the fact that the medical reports already provided to CIGNA had in fact documented such "functional deficits", Mr. Anatra proceeded to submit even more medical information to establish this, including a further narrative medical report and a Residual Functional Capacity Evaluation. Those two reports spelled out Mr. Anatra's "functional deficits" in exacting detail. However, CIGNA did not respond to either report. It just ignored them.
At that point, Mr. Anatra hired me. I submitted an administrative appeal letter and additional supporting documents. I received back a 1 ½ page boilerplate letter, upholding the initial claim denial, with no stated no rationale for the decision. The letter referenced "an Independent Peer Review" by "a Board Certified Rheumatologist". But this consultant was not identified, nor did CIGNA provide me (at that time) with a copy of any reports by this consultant. The letter also said that Mr. Anatra's administrative remedies were "exhausted" and that "there are no further rights of appeal to our office". Thus, after having augmented the claim file with undisclosed consultant reports, CIGNA sought to foreclose the entire administrative appeal process, which smacked of gamesmanship and was contrary to ERISA and well-settled case law.
The medical evidence in support of Mr. Anatra’s claim was clear. It included an independent vocational assessment, examination reports by two qualified medical specialists and a Residual Functional Capacity Evaluation. In addition to all that, the Social Security Administration had determined that he was disabled under its rules and he was approved for SSDI benefits on his first try, which is rare.
By comparison, CIGNA’s denial relied on the paper review reports of Drs. Mendez and Cole, and a third paper review report, later determined to be that of a Dr. Payne. I demanded that CIGNA produce a copy of the Payne report. In response, I received a report marked “DRAFT”, which had not been signed by Dr. Payne. This would indicate that Dr. Payne apparently sent a copy of the "draft" report back to CIGNA for its review and input, before any final report was to be issued by him. That suggested that Dr. Payne's review wasn't exactly "independent" of CIGNA. Dr. Payne acknowledged and agreed with the CFS / Fibromyalgia diagnosis, but he completely dismissed pain as a disabling factor. Although he acknowledged that Mr. Anatra suffers pain, he opined, "(T)he limitations placed upon him are primarily based upon his reports of chronic pain and debilitation there from." That analysis failed to recognize that the subjective element of pain is an important factor to be considered in determining disability. There is an enormous amount of case law on point, which refutes such an analysis.
I forwarded a copy of Dr. Payne’s report to Mr. Anatra’s treating rheumatologist, who wrote a response that eviscerated it. A copy of that report was sent to CIGNA. It was ignored. Therefore, a lawsuit was filed and the case was prepared for trial. Result: The case was resolved satisfactorily