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The O’Ryan Law Firm, on behalf of Plaintiff, Timothy E., recently filed a federal lawsuit against Life Insurance Company of North America (LINA), a subsidiary of Cigna, for their refusal to continue paying disability benefits to a city employee who had been disabled for more than 5 years. The Plaintiff was employed by the City of Bloomington, and became unable to continue working in his extremely physical job from severe back issues and cardiac problems.  He had been employed for the City of Bloomington for more than 20 years when he was forced to stop working because of his medical conditions.  Cigna paid him for 5 years and then abruptly terminated his monthly disability payments saying he had miraculously recovered his ability to return to work, after 5 years.  In the meantime, he had been approved by the Social Security Administration who found him unable to perform any substantial, gainful activity.

Facts of the Case Against Cigna

The Plaintiff was employed by the City of Bloomington from 1987 until he became disabled in June 2010 and unable to work due to coronary artery disease, back pain, COPD, hypertension, fatigue, sleep apnea, and hyperlipidemia. Plaintiff’s treating physicians provided objective medical proof that the Plaintiff was unable to continue working due to these medical conditions.

The O’Ryan Law Firm, on behalf of Plaintiff Sherry M., recently filed a federal lawsuit against Anthem Life Insurance Company (“Anthem”). The Plaintiff was employed with Anthem Life as an Operations Expert, which made her eligible for disability benefits under the Anthem Life Long Term Disability (LTD) Plan (the “Plan”).  Anthem was both her employer as well as the insurance company for her long term disability benefits.  It always is particularly troubling to see an employee, who has worked hard for a number of years for an insurance company, be mistreated when they become disabled by their own employer.

Facts of the Case

The Plaintiff was employed by Anthem Life until she became disabled in 2015 due to the disabling effects of lupus erythematosus.  According to WEB MD, lupus is an autoimmune disease, which means that the immune system mistakes the body’s own tissues as foreign invaders and attacks them. Some people with lupus suffer only minor inconvenience. Others suffer significant lifelong disability. Nine out of 10 people with lupus are women. The disease usually strikes between age 15 and 44, although it can occur in older individuals. There are two kinds of lupus:

At the O’Ryan Law Firm, we represent numerous clients who have become disabled and their disability claim was denied by their insurance company. We then represent the clients in the appeal process to appeal the denial of their disability benefits.  Lately, many of the insurance companies have be issuing late determination decisions on the appeals that we submit to those companies.  By law, an insurance company is required to issue a decision within 45 days of the date of receipt of the appeal unless an extension is warranted due to “special circumstances” but even then, a decision on the appeal must be rendered within 90 days at the latest.

The Supreme Court in Firestone Tire & Rubber v. Bruch, 489 U.S. 101, 115 (1989) held that de novo adjudication of employee benefit claims is the norm. Because the de novo standard of review is the default standard in an ERISA employee benefits case, the plan administrator or insurance company bears the burden of showing that the more deferential standard should apply. Fay v. Oxford Health Plan, 287 F.3d 96, 104 (2d Cir.2002)Marguez-Massas v. Squibb Mfg., Inc., 344 F.Supp.2d 315, 320 (D.P.R. 2004); McDonald v. Timberland Co. Group LTD Coverage Program, 2002 WL 122382, at *3 (D.N.H. Jan.23, 2002). Accordingly, once in litigation, a disability insurance company bears the burden of proving that their decision is entitled to deferential review by the Court.

The regulations governing ERISA disability claims require insurance companies to issue a decision on a claimant’s appeal within 45 days of the date that the insurance company received the appeal unless “special circumstances” warrant an extension of time for an additional 45 days; however, in “no event” shall the extension of time exceed 45 days. 29 C.F.R. §2560.503-1(i)(1), (i)(3), (i)(4).