The following is a Q & A from the many emails received and responded to regarding this website:

 

 

1.  What should be changed in the CRCC Code of Ethics to level the playing field, protect "clients" and add standards regarding Transferable Skills Analysis (TSA) referrals?

 

TheTSAScam believes the Code of Ethics as currently written rewards the least ethical among CRC Certificants in the Insurance referral business.  There is far too much gray area and too few standards in the Code leaving the door open to “pay to play” with Insurance Companies and Claims Administrators dealing in ERISA claims.  The TheTSAScam believes the following issues must be addressed in the Code of Ethics regarding Transferable Skills Analysis to level the playing field for all Rehabilitation Counselor’s:

 

1.  All documents received from the Insurance Company and/or Claims Administrator must be listed in the Transferable Skills Analysis with the dates of the documents.

 

2.  All Transferable Skills Analysis should be accompanied with a disclaimer that explicitly states that if the Rehabilitation Counselor  discovers material documents were withheld by the Insurance Company and/or Claims Administrator the TSA is “null and void”.

 

3.  Certified Rehabilitation Counselors must disclose in the TSA:

a. that they are not “experts”

b. their contact information including address, phone and email

c. their relationship, if any, with the referrer

d. the methodology utilized in preparing the Transferable Skills Analysis

e. Any and all communication, guidance and contractual coaching from the Insurance Company and/or Claims Administrator

f.  The scientific limitations of Transferable Skills Analysis

  4.  CRC’s must attempt to contact the “client”.  If the attempt fails due to time constraints and/or non-responsiveness then the CRC should disclose the attempt in the TSA.

 

 

2. Why is TheTSAScam primarily concerned with ERISA as it pertains to the CRCC and Rehabilitation Counselors?

 

The TheTSAScam believes there is a complete lack of education and understanding about ERISA in the Rehabilitation Counseling profession.  ERISA is a very complex law that was never intended to be adversarial.  Adjudication of claims is mandated to be “full and fair” which should be consistent with the CRCC Code of Ethics.  Unfortunately due to a lack of education and understanding many Rehabilitation Counselors have injected themselves in the ERISA process chasing the easy money to be advocates and “hired guns” for Insurance Companies. 

TheTSAScam believes University Rehabilitation Counseling programs, CRCC home study and CRCC continuing education programs must address this complex law.  ERISA covers millions of people and their hard earned employee benefits.  The CRCC Code of Ethics mandates that Rehabilitation Counselors should be "objective" and "unbiased" while ERISA mandates a review that is "full" and "fair".  The current race to the bottom in the Rehabilitation Counseling field is subverting both the Code and ERISA.

 

 

3.  Why didn’t the people behind TheTSAScam contact the CRCC before setting up the website?

 

The CRCC website neither lists Commission Members nor their contact information.  How do you informally contact them?  The only way to ask an ethical question of the CRCC is to file a complaint. The web site is an awareness campaign for the public domain. 

 

4.  Why does TheTsaScam think Insurers do not care about the CRCC Ethics Committee?

 

a. The Insurers look at everything through the eyes of their attorneys.  The CRCC Ethics Committee is not a Court of Law.  It is doubtful that Insurers and their attorney’s care what a group of highly educated Rehabilitation Counselors have to say.  From the Insurers standpoint, once an ERISA claim file is closed an ethical complaint and the adjudication of the complaint by the CRCC is inadmissible in a Court of Law.

 

b. The Rehabilitation Counselor is bound by the Code of Ethics not the Insurer.

 

c. The CRCC Ethics Committee has never taken a Rehabilitation Counselor employed or paid by the Insurance Industry to task for ethical violations involving bias.

 

5.  What does TheTSAScam believe is the role of Certified Rehabilitation Counselors employed by Insurers in the claim review process?

 

It is probably very difficult for Rehabilitation Counselors to live up to their ethical obligations while also producing claim denials in an Insurance setting.  Regardless, if you want the "CRC" next to your name then the “client” comes first and the employer comes second.  One thing that is extremely disturbing is the fact that Certified Rehabilitation Counselors (CRC) employed by the Insurance Industry routinely go through claim files to determine what “selective” documents should be sent on to the referral CRC.  It is a "set up" with a claim denial as the ultimate objective. 

 

6.  How does the tsa scam work?

 

TheTSAScam believes Rehabilitation Counselors engaged in the Transferable Skills Analysis referral game are in a race to the bottom.  The Insurance Companies want denials and they know very well the easiest tool to manipulate in their favor is the transferable skills analysis.  Essentially what is occurring is the Rehabilitation Counselor that interprets everything in the Insurer’s favor, doesn’t ask questions and doesn’t care about their "client" receives future referrals (MONEY).  The Rehabilitation Counselor who acts according to the Code of Ethics may not give the Insurer what they need and may ask too many questions.  In return they get very few, if not zero, future referrals.  The Insurers  track the results and they know where to go.  It usually leads to the Rehabilitation Counselors trading ethics for the referrals (Money).  Everyone  knows the Insurers are not going to waste money on an ethical CRC if the desired result (claim denial) is in jeopardy.  The Insurers know there is no reason to jeopardize an outcome because there is always another CRC willing to play the referral (money) game.

 

 

7.  Why does TheTSAScam think some Certified Rehabilitation Counselors are cowards?

 

There is nothing more cowardly than rendering a judgment about a person and their hard earned benefits while:

 

1.  Failing to attempt to communicate with the “client”

2.  Failing to provide your contact information on the TSA

3.  Accepting an Insurers selectively reviewed set of documents and failing to disclose the limitations of transferable skills analysis

4.  Running to the Insurer and hiding a behind  corporate attorney when the “client” tracks you down and tries to ask  question.

8.  Why is TheTSASCam "mad"?

 

TheTsaScam is “mad” because everyone in the Rehabilitation Counseling profession knows the Insurer claim referral game is a race to the bottom that renders the Code of Ethics a sham yet it continues unabated.  All you have to do is read the CRCC Ethical Advisories over the years and you can see that ethical CRC’s have been yearning for the CRCC to write a Code that leaves little room for Insurers to manipulate and stamps out the uneven playing field that rewards the least ethical certificants.  To date the CRCC has done neither.

 

9.  Has anyone disputed the “case study”?

 

No.  Most commenter's have expressed disgust and shock.  We had one empty charge of misinformation from an esteemed author however it was never substantiated.  The “case study” clearly illustrates the sick game Insurers are playing with people's lives while using Rehabilitation Counselors as their pawns. The Insurers wrap themselves in the CRCC Code of Ethics while simultaneously making a mockery of everything the Code is supposed to stand for.

TheTSAScam has additional cases that are just as bad.  The second is mentioned in the coming soon section of case study section - A Certified Rehabilitation Counselor working for an Insurer sends forty (40) referrals to be turned around in 17 business days by a non-CRC.  Why would a CRC bound by a Code of Ethics defer to an individual not bound by a Code?  The third involves a case where an insurer had three (3) transferable skills analysis performed on one client in a 13 month period.  All three contain different work experience, different documents, different conclusions and involved six different CRC's - three with the insurer, one with a subsidiary and two outside firms.  This case clearly illustrates the unscientific nature of TSA's and how easily Insurers can manipulate the results with "selective" input. 

10.  Would TheTSAScam consider removing the web site?

Certainly.  If the profession and the CRCC recognize the failings of the Code and take the proper corrective measures to protect the "client" from unethical acts the need for the web site will have run its course. 

11.  Why do insurers want CRC’s on their rolls? 

 

Insurers want Certified Rehabilitation Counselors (CRC’s) on their rolls because CRC’s are viewed as being held to a higher standard.  The Insurers hope that claimants will view their CRC’s as trustworthy, caring, helping and thoughtful people that are there to help the claimant.  It’s all a ruse to facilitate claim denials.  TheTSAScam considers this farce to be one big false advertising campaign that preys on the folks the CRCC claims to help.

Unfortunately, it appears the CRCC is unwilling to stop this ethical rot even though they are well aware it exists.  The CRCC may eventually have to change their “client” definition from “person with disabilities” to “Insurer and Claims Administrators”.

 

 

12.  The CRCC encourages attempts to resolve ethical issues informally.  What usually happens when an Insurer finds out a CRCC ethical charge may be filed against one of their CRC’s?

 

The Insurance Company attorneys step in and shut down any informal attempts to resolve ethical issues.  That ultimately forces ethical charges to land in the CRCC Ethics committee and leaves the Certified Rehabilitation Counselor unwittingly hanging in the wind to answer the charges.  The Insurance Company attorney’s real client is the Insurance Corporation not the Rehabilitation Counselor and the attorney knows very well the Insurer is not bound by the CRCC Code of Ethics, the Certified Rehabilitation Counselor is. 

Whether or not a CRC should accept the advice of corporate counsel regarding an ethical CRCC matter is a decision that deserves careful consideration. 

 

13.  Why is documentation within the transferable skills analysis so important?

 

It is important because Insurers routinely do not disclose documents and information related to the transferable skills analysis.  Again, the Insurers are not held to a higher ethical obligation to the “client” (person with disabilities) like Certified Rehabilitation Counselors.   If the CRCC is true their obligation to the "client" in the Code of Ethics then documenting everything related to the Transferable Skills Analysis in the TSA document should be a no-brainer.

 

The CRCC commissioners can no longer put their heads in the sand regarding the conflict that exists between the Rehabilitation Counselor’s ethical obligations to the "client" and an Insurer’s obligation to its bottom line and shareholders.  Either a CRC is a CRC in all settings or the CRCC is condoning a massive fraud on folks with disabilities.

14.  What happens if the CRCC Ethics Committee finds that a transferable skills analysis was performed in violation of ethical practice?


This is an important question.  Unfortunately there isn't a clear answer since the CRCC does not mention this scenario on its web site.  In ERISA claims the Insurer could use an unethically prepared TSA to deny benefits and the "client" (claimant) would have very little recourse regarding their benefits.  That is one very perverse situation but it is very real.

15. Should "clients" (claimants) trust rehabilitation counselors hired by  Insurers?

That is a very difficult call.  After over 17,000 views of this site and many emails the feedback is disheartening.  It appears the Insurers put serious weight on the Rehabilitation Counseling profession to produce results that flow down to the Insurers bottom line.  Eventually the CRCC will require an overhaul to save the profession from an uneven Code lacking standards that permits the the least ethical CRC's to garner the largest share of the Insurance Industry referral payouts.

16.  Why doesn't the CRCC web site contain a section for "clients" to inform individuals with disabilities what to expect from Certified Rehabilitation Counselors?

That question should be posed to the CRCC. 

17.  Does the CRCC or the Rehabilitation Counseling Profession have any groups that do pro bono ("for the public good") or low cost work to offset the massive influence of the Insurance Industry?

We are unaware of any.  This would be a very good idea because many individuals facing the Insurance Industry claim machine do not have the resources to pay for an independent TSA to submit with their appeal.  Additionally, this could be a means for the CRCC to collect TSA's that are being performed at the behest of the Insurance Industry and to insure that these Transferable Skills Analysis are being performed according to acceptable standards.  TheTSAScam believes this would also be a real check against unethical behavior.

18.  What is the purpose of a cease and desist order from the CRCC?

A cease and desist order requires the violator to cease and desist the challenged behavior.  It is a rarely used tool of the CRCC.  Over the past 15 years the CRCC averages only two per year.  The fact that the CRCC recently issued two more indicates some very questionable tactics were being employed.

19.  Has the insurer or the Certified Rehabilitation Counselor in Case Study One rescinded the findings of the TSA since the CRCC actions?

No.  The subject is still without benefits.  The CRC cowardice continues and CIGNA stated the following rationale for benefit denial:

The occupational analysis is made by a licensed certified vocational counselor.  Your advocacy is not sufficient to refute or change the vocational counselor's expert input in the review of the specific facts of your claim. - Gary Person - Disability Appeal Manager

20.  Are these manipulative claim tactics similar to the previous settlement with a major insurer?

Yes.  Amazingly some of the individuals that worked for that particular insurer now work for the insurer involved in Case Study One.  Case Study One illustrates the systemic nature of the problem.  There were so many people involved in this case including  six  CRC's, the highest levels of claim and appeal staff, a medical director and an attorney who blessed the activity every step of the way.  Not a single one of them stood up and said "Hey, are we crossing the line here".  You can find additional details of the previous claim settlement here -   Hopefully there will be another one coming down the pike to protect the American people.  This egregious conduct must cease.

21.  Does the Commission on Rehabilitation Counselor Certification (CRCC)  inform State Licensing Boards of ethical violations?

According to the CRCC Guidelines for Processing Complaints:  If a sanction (reprimand, suspension, revocation) has been issued counselor licensure, certification, or registry boards; voluntary national certification boards; and appropriate professional associations shall be notified of the results.  If a violation has been found and the Certificant's CRC certification has been suspended or revoked, a notice of the Committee action that includes the section(s) of the code that were found to have been violated and the sanctions imposed shall be published in the CRCC newsletter.

22.  Was there any surveillance in Case Study One?

Yes,  four days.  The subject never left the house for three straight days due to narcotic medications.  There were numerous gratuitous zoom-in video shots of the subject's pregnant wife bending over to pick up a two year old child and zoom-in shots of a house window.  Very disturbing.  The insurer found the surveillance tactics to be within their right and the results were not "material" because they did not get what they were looking for:

Your issues concerning the surveillance  have been  investigated  by the Customer Advocacy  Dept.  and the  surveillance was not a material consideration as part of the appeal review resolutions - Doryne Thomas - CIGNA Disability Claim Manager

We will post the disturbing video footage so that other claimants and their families will know what they will be subjected to in the course of "claim administration?  The Insurance Industry has become very aggressive in ERISA disability cases thinking they have nothing to fear.   The corporate policy playbook involves vocational experts, claim administrators, surveillance contractors, medical directors and attorneys.

23.  Was the surveillance material provided to the Certified Rehabilitation Counselors involved in Case One?

The CRC's working for CIGNA may have been aware of the surveillance since they have access to the internal systems.  The CRC's performing the  transferable skills analysis did not mention the surveillance so you can assume they were unaware of the surveillance.  Is evidence that an individual was incapable of leaving his/her house for three consecutive days due to narcotic medications relevant to a TSA?  The report conclusions per the carriers Special Investigations unit was:

Surveillance was conducted and the claimant was found to be mostly inactive.  Further investigation is not warranted at this time -
Jenna Holder CIGNA Investigations (Click here)

24.  Was transportation to/from work and driving an issue in this case?

Yes. Here are the  contradictions encountered by the claimant while the definition of disability remained constant.  The CRC's did not address transportation to/from work in the TSA's.


From the administrative record...

• The problem is how will he get to work? Driving or walking is a problem.  Becky Schomer (1997) benefits payable (Click here)
  

• We will have to watch his R & L's, especially walking and driving - Becky Schomer (1997) benefits payable (Click here)
  

• Can't handle walking, climbing, issues to and from work - (2005) benefits payable (click here)
  

Then in 2006-7 .....

• Transportation to and from the workplace is not part of our analysis when determining your ability to function and/or work.  It is our position not to consider transportation to and from the workplace - Latonya Puckett - CIGNA Senior Claim Manager (2006) adverse determination - benefits denied
  

• The ability to get to and from work is not a material duty of an occupation - Karol Johnson - CIGNA Appeal Specialist(2007) adverse appeal determination - benefits denied
  

• Commuting is not a material duty.  Even if at some time in the past the commute was considered, that does not make the current vocational analysis incorrect - Gary Person - Disability Appeal Manager (2007) adverse appeal determination  - benefits denied
  

25.  Were there issues related to narcotics (oxycontin) and the ability of the claimant to work?

Yes.  The Certified Rehabilitation Counselors did not address the effects of narcotic usage on the ability to acquire and hold work after a ten year absence.  Here are the medical assessments:

• Patient remains on chronic opioid treatments (oxycontin) which may impair his judgment relating to work and travel.  This is an extremely severe issue and needs to be taken into account for any type of job activity using mental skills.  Patient clearly has significant physical disability which is compounded severely by the chronic opioid issues.  The suggestion that employment options that require clear sustained mental faculties are an option for this patient is inconsistent with the facts - Treating Physician - Board Certified Orthopedic Surgeon (Click here)
  

• Records indicate patient suffered a seizure resulting from pain medication. Patient suffers cognitive impairment due to narcotic usage.  Fine finger manipulation may be limited due to medication effects. Patient had difficulty with simple arithmetic subtracting serial 7's from 100 that may possibly relate to medication side effects. Independent medical examiner - Board Certified in Physical and Rehabilitation Medicine licensed in State of Patient's residence (Click here)
  

• Has chronic pain management problems and is on long term heavy doses of oxycontin - Peer Reviewer - Board Certified in Orthopedic Surgery licensed in State of Patient's residence (Click here)
  

• Received Orthopedic Specialist/Peer review report who found that the provided medical records are sufficient to support Restrictions and Limitations that would prevent sedentary activity during the time period in question....because of claimants ongoing use of Oxycontin he would be unable to work. Karen Haley - Registered Nurse (Click here)

Contrast the above with......

• My assessment in my opinion, with a reasonable degree of medical certainty the reviewed medical documents do not demonstrate that claimant is incapable of performing sedentary work activities.  Opioid use does not preclude non-safety sensitive work activities - Robert Anfield, Medical Director, Board Certified Family Medicine - unlicensed in State of claimant's residence (Click here)
  

• Another medical review was conducted by a Medical Director (Dr. Robert Anfield) specializing in Occupational Medicine...The Medical Director's assessment is...opiod use does not preclude non-safety sensitive work activities - Doryne Thomas - CIGNA Claim Manager -adverse determination letter
  

26.  In determining sedentary capacity it is important to determine the ability and duration of sitting.  Were there conflicting medical assessments regarding sitting between the physicians and the medical director?

Yes. 

• The treating physician (board certified in orthopedics) noted that patient "required the ability to move around from a sedentary position every ten to fifteen minutes for at least five minutes"

• The IME physician (board certified physical medicine and licensed in patient's State) noted that "pain complaints are supported by objective findings on examination...I believe his orthopedic surgeon  could better comment about the specifics of his knees...patient will need bi-lateral knee replacements...patient needs reasonable accommodation in terms of moving around." (click here)
  

• The Peer Review physician (board certified in orthopedics and licensed in patient's State) noted that patient "requires frequent position changes with changing positions every 10 to 15 minutes." (click here)

Contrast the above with....

• CIGNA's Medical Director (Dr. Robert Anfield, family practice and unlicensed in patient's State) noted patient's "medical history restricting the activities of standing, walking, climbing, stooping, kneeling, crouching or crawling is medically reasonable".  NO RESTRICTION OR LIMITATION ON SITTING, SEDENTARY or POSITION CHANGE. (click here)
  

27.  I see numerous instances of cherry-picking in this ERISA disability case.  Did the treating physician address it?

Yes and in no uncertain terms.  In a letter to CIGNA's Latonya Puckett the treating physician wrote the following: (Click here)

I find it extremely embarrassing that you have chosen to pick and choose, and more or less cherrypick out of letters to support, pause and ignore other statements by physicians.....Even more astounding is the fact that you have chosen to ignore the closing sentence which states patient is on chronic opioids which may clearly impair his judgment....to ignore these restrictions and say you are not responsible  and then say there are hypothetical jobs, to me misses the point of the orthopedic evaluation...

28.  Do Insurers utilize unqualified, unlicensed medical opinions or questionable vocational assessments to deny benefits at the end of administrative remedies in ERISA Disability cases? 

       

Yes, insurers will close out appeals (administrative remedies) utilizing questionable expert opinions simply to force the case to the brink of judicial filing where the insurers receive numerous legal benefits.  The insurers use this perverse legal strategy hoping a claimant will give up because he/she does not have the resources to hire an attorney.  Paying unqualified or unlicensed experts to render decisions is a small price to pay  for the 100's of millions of dollars in savings each year.  It is a dishonest strategy that yields a high return.
          

29.  Were the highest levels of Cigna's corporate structure copied on communication in this case?

Yes.  CIGNA's President, Executive Vice President & General Counsel and Senior Vice President were copied throughout the administrative process. 

30.  How much was CIGNA willing to pay for the IME, Peer Review, disability consultant/medical director, two (2) vocational assessments and four days of surveillance to achieve the desired claim denial?

It is unclear how much money the CIGNA spent on this claim denial.  The claimant requested all relevant documents, including invoices, pursuant to ERISA claim procedure.  The Insurer denied access to invoices stating the following in the adverse determination letter:

"Invoices are not a relevant item" - Gary Person - CIGNA Appeal Team Manager   

31.  Did the CIGNA provide written procedures or protocol that guide the administrator's decisions?

No. Any internal rule, guidelines, protocol or similar criterion were requested many times.  The insurer refused to comply with the request and stated the following evasive answer to the request:

To the extent any internal rule, guideline, protocol, or similar criterion is relevant as a basis for any action in your claim, is contained in the file.  Any other items you request are proprietary and confidential property... - Gary Person - CIGNA Appeal Team Manger

32.  A case (Combe v. Life Insurance Company of North America) was posted on the THETSASCAM homepage that is a complete smack-down of CIGNA's disability claim tactics.  Do you believe it changed the way CIGNA does business?

Apparently not.  That legal case was decided on June 21, 2007.  The case study on this website had the final appeal determination on August 28,  2007.   If you read the case documents the Court  really  blasted  the  Insurer's tactics  however it was not enough to stop those tactics from claiming another victim.  The Court noted the following:

• In his letter affirming the administrators initial denial on appeal, Gary  Person, identified as Manager Centralized Appeal Team, explained as follows...Person's two page explanation of CIGNA's denial ... does not even mention ...one of the two medical conditions... Neither does it discuss the duties of Combe's regular occupation...

• There is no mention that the Medical Director's who reviewed Combe's appeal, or for that matter, Mr. Person, actually reviewed the additional information regarding the material duties..

• Apparently, in CIGNA's view, as long as Combe's job duties did not require him to operate heavy equipment, work on an off-shore oil platform, drive a vehicle or physically endanger others, it should be perfectly acceptable for him to sleep on the job, or when awake, to be fatigued, unable to read and comprehend a short legal article, unable to focus on an issue, and unable to interact with or supervise others during the normal work day.

•  Neither did the administrator explain where in the Plan documents, statutory or regulatory language, or jurisprudence,  there  is  language requiring  the claimant  to  submit  to  a  specific  test  or  testing  in  order  to  objectively  prove  a  claimed  disability  that  has been diagnosed  by  a  treating  physician  and  supported  with  physicians  office  notes,  examinations  and  testing.

•  CIGNA produced no copies of internal written procedures or protocols to guide the administrator's... so this Court can not review the internal consistency of the administrators evaluation of Combe's claim in light of internal procedures or protocols...
  

Note that CIGNA did not like the decision and requested a new trial.  The Court stated the following in the "Ruling on Motion" while denying the request:

• This Court's forty-one page ruling on the motions for summary judgment ... concluded that CIGNA had not given the plan the correct legal interpretation (page 20); that there was no evidence in the administrative record supporting CIGNA's decision that Combe was not disabled under the terms of the plan (page 35); that CIGNA had disregarded overwhelming, uncontroverted evidence...(pages 32-38) "that CIGNA's handling of Combe's claim was perfunctory and superficial and not in good faith; that CIGNA failed to provide a full and fair review of Combe's claim; and finally that CIGNA's finding that Combe was not disabled under the plan "was arbitrary and capricious and an ubuse of discretion"...
  

32.  Are there any other web sites exposing the Insurer - Certified Rehabilitation Counselor TSA Scam?

Yes.  Please visit the other site www.transferable-skills-analysis.com

 

 Additional Questions answered subsequent to Good Morning America's expose regarding Cigna Disability:

 

 33.  Did Cigna respond within 45 days to the first appeal?

The answer is no.  Cigna failed to respond in 45 days nor did they respond in 90 days.  Cigna's Gary Person sent a letter with a litany of excuses and with an open-ended deadline.  The  appeal response was not received until over 100 days had elapsed.  Click here for Gary Person's letter.

 

 34.  What was CIGNA's response to the final appeal?

The final appeal contained fifteen (15)  items.  Cigna's response from Doryne Thomas essentially ignored most of the issues.  The  appeal items were as follows:

Appeal Item One - Issue with Transportation to/from work

Appeal Item Two - Fabrication based on logical fallacy

Appeal Item Three - Misconstruction of the record

Appeal Item Four - Wrong definition of disability - Failure to follow ERISA

Appeal Item Five - Experts contradict Cigna's determination

Appeal Item Six - Blank check to commit fiduciary wrongs

Appeal Item Seven - Oxycontin - cognitive impairment - employment

Appeal Item Eight - Cigna not consistent as required by ERISA

Appeal Item Nine - Non-production of documents

Appeal Item Ten - Transferable Skills Analysis materially flawed

Appeal Item Eleven - Cigna disregards Social Security Award

Appeal Item Twelve - Additional Medical Submission

Appeal Item Thirteen - Plan Sponsor does not accept Cigna's decision

Appeal Item Fourteen - Issues related to Surveillance - Pregnant Wife

Appeal Item Fifteen - Contract contains rehabilitative work provision

Final Adverse Determination letter August 2007 - Doryne Thomas

35.  What were the circumstances surrounding the initial benefit denial?

The initial benefit denial was received in May of 2006 three months after the claimant's twelfth knee surgery and while the claimant was still in rehabilitation.  The letter retroactively denied benefits and was based on erroneous salary and Transferable Skills Analysis information and the opinion of a non-specialist even tough Cigna has the fiduciary responsibility in ERISA to utilize a health care professional with the appropriate training and experience in the specific field of medicine, here orthopedics, involved in the medical judgment.  Below you will find the major appeal items from the first appeal.  Cigna denied the appeal in Karol Johnson's letter dated January 2007.  The denial failed to address many of the issues presented in the appeal.

Initial Adverse Determination letter May 2006 - Latonya Puckett -

First Appeal Item One - Cigna uses incorrect wage data in TSA

First Appeal Item Two - Cigna fails to produce medical documents

First Appeal Item Three - Cigna fails to use appropriate medical professional

First Appeal Item Four -  Issues with transferable skills analysis

First Appeal Item Five - Cigna refuses to separate policies with different terms

First Appeal Item Six - Retaliation and Rush - Why?

Adverse Determination letter after first Appeal Jan. 2007- Karol Johnson

Supplemental Information Related to the Appeals:

Peer Review Report -

Independent Medical Evaluation

Claim Notes regarding transportation1

Claim Note regarding transportation 2

Nurse Claim Manager report

letter - Treating Physician to Latonya Puckett May 2006

letter - Treating Physician to Karol Johnson March 2007