At age 67 Mr. H continued to maintain the desire to work in his occupation as a circuits designer for wireless telecommunication giant, Qualcomm. Unfortunately, his career was cut short after suffering a bad fall resulting in a broken rib severely puncturing his lung. Due to complications, Mr. H was placed in a medically induced coma for 34 days. Making matters worse, while in the coma Mr. H contracted viral pneumonia. After waking from the coma Mr. H found he was forgetting things easily and often; he was losing his train of thought and having trouble navigating familiar environments. He also began experiencing symptoms of depression and anxiety. Mr. H was obviously suffering symptoms of cognitive decline and impairment and his doctors were unsure whether he suffered a traumatic brain injury in his fall, was suffering residual complications from his coma or whether he was experiencing dementia.
While in his coma, Mr. H’s employer assisted with filing his short-term disability claim. Mr. H’s short-term disability claim, which was self-funded by Qualcomm, was promptly approved and paid for the full 26 week period. Unfortunately, following the 26 week short-term disability period, Mr. H’s symptoms continued and worsened. As a result, he was forced to file a claim for long-term disability under Qualcomm’s long-term disability plan, which was administered and funded by The Prudential Insurance Company of America (“Prudential”).
After submitting his claim, Prudential approved benefits for 2 months and then terminated Mr. H’s claim stating that he could return to his regular occupation. To support its termination of benefits, Prudential surprisingly claimed that the medical data did not document that Mr. H had sustained a serious fall that resulted in a prolonged hospitalization and residual side effects. This was particularly shocking since Prudential was aware that Mr. H had been placed in a medically induced coma for 34 days and had suffered several serious health complications as a result.
After receiving his letter from Prudential terminating his claim, Mr. H contacted Dell & Schaefer and retained Attorney Cesar Gavidia to represent him with his appeal of benefits. Mr. H’s appeal, which included a neuropsychological examination report by a well-respected and credible neuropsychologist and verified the extent of Mr. H’s cognitive problems, was submitted to Prudential within the 180 day window prescribed by the Employee Retirement Income Security Act (“ERISA”). Shockingly, despite the overwhelming medical support and the compelling proof of cognitive deficits described in the neuropsychological report, Prudential upheld its decision to terminate the claim.
Mr. H, through Attorney Gavidia, filed suit in federal court alleging that Prudential violated ERISA by failing to pay his claim for long-term disability benefits. Mr. H sought not only recovery of all of his unpaid long-term disability benefits, but also attorney fees and costs under ERISA. Soon after suit was filed Mr. H and Prudential engaged in settlement negotiations. Eventually, the parties reached a mutual compromise where Prudential agreed to settle Mr. H’s claim for an undisclosed lump sum and Mr. H agreed to dismiss his lawsuit against Prudential.