Cigna Denial Reversed! Hormone Therapy is Not Treatment That Limits Cancer Disability Claim Coverage

Insurers are still permitted to include “pre-existing” limiting provisions in its disability policies. Cigna policies provide that ” The Insurance Company will not pay Disability Benefits for any period of Disability caused or contributed to by, or resulting from a Pre-Existing Condition.” A “Pre-existing Condition” means “any Injury or Sickness for which medical treatment, care or services including diagnostic measures, prescription drugs or medicines was recommended or received from a licensed medical practitioner within 3 months before the Employee’s most recent effective date of insurance.” Cigna has a pattern of discriminating against women suffering from breast cancer. See ABC news report from 2009. They again committed bad faith in 2014 when they applied the pre-existing provision to our client, Ann-Marie, denying her bona-fide claim for disability due to metastatic breast cancer.

In 2007 Ann-Marie was diagnosed with breast cancer during a routine mammogram. She underwent surgery and chemotherapy and returned to work. For the next six years, she saw her doctor for bi-annual cancer screening and received monthly adjuvant hormonal therapy purely as a preventative measure, because the breast cancer had a large number of estrogen receptors. The treatment reduces the body’s own production of estrogen. Ann Marie changed jobs last year and received new group long term disability benefit coverage with Cigna.

Our client had symptoms of metastatic cancer four months after she began her new employment and Cigna denied the claim, asserting that her treatment of Zoladex in the three months pre-employment qualified as “treatment for cancer”.
We appealed the denial, arguing that there is no evidence that Ann-Marie had cancer during the three month pre-existing time period and since she did not have cancer, she could not have received treatment for a sickness that she did not have.

She had no sickness for which medical treatment, care or services was provided
She was not treated for metastatic breast cancer She received no care for metastatic breast cancer She received no services for metastatic breast cancer She received no diagnostic measures for metastatic breast cancer She received no prescription drugs or medicines for metastatic breast cancer No prescription drugs or medicines for metastatic breast cancer were recommended to her.

By the very terms of the Policy, Ann-Marie was not sick at the time, did not take medication for a sickness, did not treat or consult with a physician for a pre-existing sickness, because she was not sick. She took hormone drugs to prevent cancer; it was not FOR cancer. She could not have taken medication or received treatment during the pre- ex period FOR a sickness that she did not have and her physicians do not claim she suffered from.

We were notified just before Christmas that Ann-Marie’s claim was approved!

If you have a claim pending for disability and the insurer has applied the pre-existing limiting provision to your case, we suggest that you consult with an attorney to review the medical records that exist during the crucial three month period of time before you became insured under the policy. We at Bonny G. Rafel can help. Bonny G. Rafel, LLC we advocate for patients with disabling conditions. We may be able to assist you in getting the benefits you deserve.

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