GMA Gets Answers: Insurer Delays Long-Term Benefit Coverage

April 25, 2008 — -- To see Susan Kristoff relaxing near her home in West Palm Beach, it's hard to imagine she has been fighting two very difficult battles.

One is against a potentially deadly form of breast cancer. Her other battle has been against her insurance company.

"I've moved twice, but I still have a place to live. But if it wasn't for my family, I wouldn't," Kristoff told "Good Morning America."

Kristoff was working at Yellow Book selling advertising 1½ years ago. The job entailed lugging the heavy books to meetings with potential clients. It was a job she loved, until one day a visit to the doctor brought terrible news.

She was diagnosed with stage 4 metastatic breast cancer, and it was spreading throughout her body.

"It was awful, and I was extremely tired -- limping, sharp pain," Kristoff said.

Doctors said there was no way she could do her sales job anymore. The cancer had actually eaten holes through her hips. Her company had no other position to offer her, so Kristoff filed a claim for disability insurance.

Like millions of Americans, she paid a small amount each month -- $20 in her case -- to cover her financially should she be unable to work. One-third of Americans have some form of disability insurance.

For Kristoff, paying Cigna for disability insurance was the easy part. Collecting the insurance was a different story.

"It was a daily, eight-hour job just trying to fulfill the information that Cigna was requesting," she said. "And it wasn't once. It would be over and over again."

But after five months of submitting forms, Cigna denied Kristoff's claim for short-term disability. Cigna said she had not proven a disability. Sick and with bills piled up, Kristoff says she considered something drastic.

"If I wasn't going to be getting better, I didn't want to sink the rest of my family, so I spent two days in bed crying and thinking about suicide," she said.

Instead Kristoff hired an attorney. In short order, Cigna reversed course and paid her short-term benefits. Then with her lawyer's help, she applied for the much more important long-term help.

Delay Tactics

Her policy promised to pay her 60 percent of her salary if she was too disabled to work.

This time Cigna raised a different objection, saying because Kristoff had a different form of cancer two years before she was diagnosed with the breast cancer that had metastasized, she did not qualify for disability. Doctors say the two cancers are unrelated, and she had been diagnosed as cancer-free well before she began her new job.

"I'm appalled, I'm disgusted, but I'm not surprised because there are hundreds of Susans, many of which I'm representing currently," said Kristoff's attorney, Alicia Paulino Grisham.

Grisham says she's seen this tactic before and it's called "slow walking."

"The insurance companies understand that if they deny and deny claims, then many of the claimants will never pursue their claim," Grisham said.

Law professor and former White House staffer Sara Rosenbaum agrees. She says federal law protects insurers from costly punitive damages from consumer lawsuits, giving them an incentive to delay.

"Where consumers get their disability benefits through an employer benefit plan, they are virtually powerless against a disability insurance company," Rosenbaum said.

"GMA" asked Cigna to talk about Kristoff's case, but it refused. Instead, the insurer referred us to Susan Pisano, a representative of the insurance company trade group America's Health Insurance Plans.

"I think our community has every incentive to continue to get better and that's what we strive for," Pisano said.

Chris Cuomo asked Pisano, "What is the incentive for the insurance company to do things quickly when there is no penalty for doing things slowly?"

"Well, you set up punitive damages as the sort of holy grail," Pisano replied.

Cuomo pointed out that punitive damages were set up to encourage companies not to delay coverage, knowing that there could be stiff financial penalties down the road.

"And I think that the people who wrote the law said they weren't gonna do that because they wanted to be encouraging employers to offer these benefits and they did not want to build in a costly and protracted, you know, court situation," responded Pisano.

"Delay tactics are a killer in this situation -- it's, 'How do I pay for gas? How do I pay for food? Where's my day-to-day money? I'm caught up for weeks, months, over a year,'" Cuomo said.

Pisano replied, "I think that it's a balance. The people who framed this law tried to strike a balance, giving every opportunity to make the case, for there to be a fair and thorough review."

Finally, Some Good News

"GMA" got involved in Kristoff's case as she was awaiting the results of yet another appeal.

It had been 1½ years since her cancer diagnosis, but shortly after "GMA" called Cigna on her behalf, Kristoff got some good news.

Cigna announced that based on "additional information … her disability benefits would be covered " after all.

We were curious to know exactly what new information had changed Cigna's mind, but it refused to comment.

"It's not additional information," said Grisham, Kristoff's lawyer. "The only thing that changed in this case is that 'Good Morning America' started calling Cigna. And they knew that there was a good chance that their normal insurance delay tactics would be exposed."

Kristoff added, "The insurance companies know if they just ask for more information and more information and more information, a lot of times the people don't make it."

Kristoff received an experimental cancer vaccine, and her health is much improved, but not enough for her to go back to work.

And earlier in April, Kristoff received a check from Cigna for long-term disability, and she will continue to get paid by Cigna as long as she is unable to work.

Click here to read statements from Cigna regarding this story.