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November 20th, 2014

The Ninth Circuit Court of Appeals in Salomaa v. Honda LTD Plan 637 F.3d 958 found that CIGNA’s Insurance Company’s decision to deny disability benefits to a claimant with chronic fatigue syndrome was illogical, implausible and without support because:

  • Every doctor who personally examined the insured concluded that he was disabled;
  • The Plan Administrator demanded objective tests to establish the existence of a condition for which there are no objective tests;
  • The Administrator failed to consider the Social Security Disability Award;
  • The reasons for denial shifted as they were refuted, were largely unsupported by the medical file, and only the denial stayed constant;
  • The Plan Administrator failed to engage in the required “meaningful dialogue.”

The Court found that in a disability claim that turned upon subjective evidence, such as the amount of a claimant’s pain and fatigue, it was an abuse of discretion for the insurer to rely solely upon doctors who merely reviewed the records without examining the patient when there was a uniformity of agreement by treating physicians what the individual was disabled.

Another important feature of the case was the Ninth Circuit confirming that CIGNA’s physician report is one of the documents that the Plan is required to provide the claimant as part of its duty to provide a full and fair review.  Most importantly, the Court held that these physicians’ reports must be provided prior to a final determination.  This allows the claimant or his/her physician to comment on or rebut the insurer’s physician report prior to a final determination on appeal.

July 25th, 2012

Our client was in a serious auto accident at the age of 22, which confined him to a wheelchair due to serious back injuries.  Despite his serious disability, he returned to school to learn computer programming.  He successfully returned to the workforce and became a program manager for Oracle Corp.  Due to a combination of his serious back injuries and the wear and tear after 17 years of working as a computer programmer and manager, his back finally gave out, precluding him from working full time.  He applied for and received long term disability benefits.

Four years later, on December 23rd, the insurance carrier placed our client under video surveillance.  The video showed him Christmas shopping with his wife for several hours.  Client was driving with his specially equipped vehicle, getting in and out of his car into his wheelchair and going to various stores.  Based on the video and client’s refusal to take constant pain medication, his benefits were terminated.  Stennett & Casino had our client tested through a Functional Capacity Evaluation and had his doctor prepare additional reports; however, the insurance company refused to pay additional benefits.   We filed a lawsuit in Federal Court and the court found in our client’s favor.  In referencing the surveillance video the court noted that “the plan does not require a claimant to be utterly helpless in order to be eligible for disability benefits…and plaintiff would hardly be the only person overtaxing his abilities when shopping on December 23rd.”

July 25th, 2012

Our client was a pharmacist for 32 years.  His back began to bother him the last 6-7 years before he was unable to continue work.  Pharmacists must be on their feet almost all day and his back condition precluded him from standing more than 20 minutes at a time.  The disability insurer denied benefits after doing a job survey to determine that other employers (not our client’s) would allow him to use a stool to accommodate his back problem.

Stennett & Casino retained a vocational expert who performed a more thorough job market survey and found that although employers by phone indicate they will accommodate a disability, when it comes down to actually hiring among several applicants, the disabled are often left out.  Insurers cannot use theoretical jobs as a basis to deny benefits.  They must look at the real world market place in determining if one can return to work.  Based on our vocational expert’s report and more thorough medical documentation of our client’s physical limitations, we were able to conclusively document our client’s disability, resulting in the insurer voluntarily paying disability benefits.

July 5th, 2011

Denial of Disability Retirement Reversed

Stennett & Casino’s client was employed by the County of San Diego for over 10 years in a clerical position.  She had to stop work because of an injury to her knee resulting from continued banging against a desk when she was placed in an awkward work station.  Despite the fact that she underwent 4 unsuccessful knee surgeries that left her with severe standing and walking limitations and severe pain with extended sitting, the County asserted that it could accommodate her limitations and continue to provide her a sedentary position.

The County denied the client’s claim for disability retirement.  The employee hired Stennett & Casino to represent her at a fact finding hearing.  The primary issue was whether the employee had a “permanent incapacity” precluding her from performing work for the County.  Stennett & Casino had the treating physicians focus on this issue and were able to convince the hearing officer that her constant pain and distress associated with her knee, no matter what position she was placed, precluded her from any full time employment.  Client received her disability retirement benefits.

May 25th, 2011

Our client was a financial analyst for a large defense contractor.  She had to stop work due to severe symptoms related to her diagnosis of Lupus.  Lupus is an autoimmune disease in which the immune system attacks one’s own body.  Our client was treated with medication to suppress her immune system, which exposed her to other illnesses and infections which her suppressed immune system could not fight. Read more


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