Articles Posted in Surveillance

Cigna, headquartered in Bloomfield, Connecticut, is a global health services organization and its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and services, the majority of which are offered through employers and other groups. CIGNA is one of the top health insurers in North America, with medical plans covering nearly 12 million people. Cigna operates in 30 countries, has approximately 40,000 employees and manages around $54 billion in assets.

CIGNA is the parent company of Life Insurance Company of North America. Life Insurance Company of North America (“LINA”) offers group life, accident, and disability insurance to employers. LINA was formed in 1956 by Insurance Company of North America (INA), a CIGNA predecessor company. LINA provides group disability insurance to many employers across Indiana including Toyota, the University of Notre Dame, State Farm, Sony Electronics, Covance and many others. Employees of these companies are provided short and long term disability benefits if they become unable to work due to injury or illness. LINA is responsible for processing the claims and making monthly benefit payments if the claimant proves that they are disabled and unable to return to their own occupation.

During the claims process, LINA will have a Nurse Case Manager review the medical records to determine whether an individual meets the definition of Disabled under the terms of the policy. If necessary, the Nurse Case Manager will escalate the review to a Cigna Medical Director who is an employee of Cigna. The Medical Director will also review the medical records and reports to determine whether the restrictions and limitations listed by the claimant’s treating physician are supported by the medical records. It is not uncommon for the Nurse Case Manager and Cigna Medical Director to disagree with the treating physician and to find that the claimant is able to return to work despite the medical evidence supporting the claim.
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Functional Capacity Evaluations (“FCEs”) are a type of test used to determine the severity of someone’s physical impairments. FCEs are common in disability insurance claims, workers compensation claims, and other contexts where the level of a claimant’s injury or sickness needs to be evaluated.

FCEs are usually administered by a physical therapist or physician who specializes in occupational medicine. Common measurements during an FCE include how much the claimant can lift, how much they can push and pull, how long they can walk and stand, how long they can sit, the ability to reach in all directions, the ability to grasp and manipulate with each hand, the degree to which a claimant can move all joints, the ability to squat and bend, and the ability to stoop and balance. FCEs can vary in duration: some FCEs are very brief – only a couple of hours – and some FCEs are actually performed over the course of two days.

In long term disability insurance cases, many insurance policies allow the insurance company to request that a claimant undergo an FCE at a facility of their choosing. A claimant’s refusal to undergo such testing may give the insurance company grounds to deny disability benefits. Therefore, it is likely that the claimant will have to comply with the insurance company’s request for an FCE. However, a claimant may want to consider the following tips before attending an FCE:
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Disability insurance companies may look to more than just medical records and reports when determining whether a claimant qualifies for disability insurance benefits. Insurers have long used private investigators to perform surveillance of claimants in order to obtain additional information regarding the claimant’s restrictions and limitations. Oftentimes, the private investigators are asked to document their observations with video to provide tangible evidence of the claimant’s daily activities and abilities. Depending on the information gathered, reports from the investigators’ surveillance and the associated video evidence can lead to a denial of disability benefits. Generally, when courts review video evidence they look at whether the observations in the surveillance video are consistent with the claimant’s reported restrictions and limitations.

A common strategy for disability insurers is to schedule surveillance at a time when the claimant has a scheduled appointment with their doctor or a previously scheduled medical examination. This provides the private investigators with a known opportunity to observe the claimant outside of their home. Inevitably, this allows the surveillance team to observe the claimant driving or riding in a vehicle. In Mote v. Aetna Life Insurance Co., 502 F.3d 601 (7th Cir.2007), Aetna’s decision to deny the plaintiff’s disability benefits was upheld by the court. Aetna based their decision in part on video surveillance showing the plaintiff running errands, driving to medical appointments, and loading groceries into her car. This evidence was used to establish that the plaintiff could work in “any occupation.” However, video surveillance in Gessling v. Grp. Long Term Disability Plan for Employees of Sprint/United Mgmt. Co., 693 F. Supp. 2d 856, 864 (S.D. Ind. 2010) only showed that the claimant was capable of driving a little longer than the fifteen minutes he reported to a Hartford Life representative. The court in Gessling found that this video evidence “says nothing useful about (the claimant’s) ability to work in his own occupation.”

Similarly, the Northern District of California found that surveillance evidence depicting a plaintiff “walking, driving and doing errands … for a couple of hours … does not mean that [that p]laintiff is able to work an eight-hour a day job.” Thivierge v. Hartford Life & Accident Ins. Co., 2006 WL 823751, at *11 (N.D.Cal. March 28, 2006). The Eastern District of California reached the same conclusion in a case where Hartford procured surveillance video of the plaintiff driving to the store, visiting a friend, carrying a small bag, and sitting through an interview while taking numerous breaks. Leick v. Hartford Life & Acc. Ins. Co., 2008 WL 1882850 (E.D. Cal. Apr. 24, 2008). The court determined that the plaintiff’s documented activity on a “good day” did not contradict that the plaintiff was unable to perform a full-time sedentary job. Id. See also Hunter v. Life Ins. Co. of N. Am., 437 F. App’x 372, 378-79 (6th Cir. 2011) (surveillance of a plaintiff driving to her functional capacity evaluation, as well as other activities of daily living, did not indicate that Hunter can perform all the physical duties of her former occupation).