Complaint Against Cigna Group Insurance Alleges ERISA Violation

On Dec. 31 in the Eastern District of Missouri, an individual filed a complaint against Life Insurance Company of North America (doing business as Cigna Group Insurance) alleging that Cigna breached its statutory, contractual, and fiduciary obligations and violated the Employee Retirement Income Security Act (ERISA).

The plaintiff previously was an employee of the Dolan Company, which provides its employees long-term disability (LTD) benefits through Cigna. In 2015, the plaintiff stopped working because of complications post-chemotherapy and post-operation for breast cancer, including “issues with an axillary seroma requiring incision and drainage and ongoing issues with pain and weakness in her right upper extremity, including lymphedema,” the complaint said. The plaintiff also has dealt with other health conditions, including “chest pain, lifelong intractable chronic migraines, double vision, poor memory, fatigue, neuropathy in her feet and hands, vertigo, a frozen right shoulder, diabetes, major depression, post-traumatic stress disorder (PTSD) in relation to her breast cancer, seizures, rheumatoid arthritis, and secondary parkinsonism,” according to the complaint.

At the time when the plaintiff’s physicians and psychiatrists determined that she would no longer be able to work, according to the complaint, the plaintiff was eligible to receive LTD benefits and waiver of premium (WOP) benefits for her breast cancer diagnosis and post-operative complications. 

However, on April 18, 2017, Cigna claimed the plaintiff was no longer eligible for WOP benefits, so the plaintiff appealed Cigna’s determination on June 8, 2017. Then, on Sept. 17, 2019, Cigna determined that the plaintiff “was no longer disabled and no longer qualified” for her LTD benefits. The plaintiff also appealed this determination and filed a second WOP appeal on Nov. 8, 2019. In May 2020, Cigna upheld its determinations, and another LTD appeal by the plaintiff was denied in October.

Cigna made these determinations despite documentation provided by the plaintiff in her appeals outlining her medical history and treatment/care by her physicians from 2015 through 2020, the complaint said. Among her suggested restrictions were “only stand(ing) or walk(ing) occasionally for 0-2.5 hours a day” and “only occasionally lift(ing) more than 10 pounds.” After receiving a functional capacity evaluation (FCE), the plaintiff submitted the results to Cigna on Aug. 26, which explained that the plaintiff “was not able to safely perform sitting for long periods, standing for long periods, lifting and moving work required weights, and walking work required distances.” 

Nonetheless, “Cigna determined that Mrs. Wendel was able to perform sedentary level work, which was defined by the Dictionary of Occupational Titles and expanded upon by Cigna as work that involves sitting ‘most of the time,’ ” the complaint explained. The complaint argued that the plaintiff does not meet the criteria for being able to perform sedentary level work because of the FCE report findings.

“Despite providing substantial evidence that she has been continuously totally disabled under the terms of the Plan, Cigna has denied, and continues to deny, (the plaintiff) her LTD benefits since 2019 and her WOP benefits since 2017,” the complaint claimed.

The plaintiff argued that Cigna was acting as a fiduciary as the administrator of the plaintiff’s claims, and in terminating the plaintiff’s benefits, the company “failed to adequately consider the facts and circumstances regarding her claims, failed to adequately investigate the facts supporting her claim, and relied on biased reviews” of her medical conditions, thus breaching its duties under ERISA for failure to handle the plaintiff’s benefits claim in a “careful, skillful, and diligent manner.”

Requested by the plaintiff are an order that the defendants pay all benefits claimed by the plaintiff that she claims to be owed, a declaration of the plaintiff’s entitlements under the Cigna plan and clarification of rights to future benefits, that the defendants “provide a procedure for a full and fair review of adverse determinations” and discharge their fiduciary duties, and payment from the defendants for legal fees, among other proper relief.

The plaintiff is represented by Gallagher Davis LLP.