Our client, Ms. L, formerly worked as a Control Officer for a large financial services institution. In May 2016 a number of medical issues, including Lyme Disease, babesiosis, Fibromyalgia, CFS, vertigo, vestibular dysfunction migraine headaches forced Ms. L to stop working and submit her claim for disability benefits, first under her employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by Prudential. Under her employer’s LTD policy, she would be considered totally disabled if she was unable to perform the main duties of her “own occupation” as a Control Officer.
After paying Ms. L for the maximum benefit period under the STD policy, which relied on a definition of total disability nearly identical to that in the LTD policy, Prudential denied LTD benefits on the basis that she allegedly no longer met the policy definition of disability. Specifically, Prudential stated that her “claimed conditions… are not supported by the medical evidence available…[and] no restrictions and/or limitations are supported by the physical/neurological examinations performed, on the imaging studies, on physiological studies or on the laboratory testing provided.” After receiving the denial, Ms. L contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Prudential’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. L’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Sun Life’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Prudential’s denial and significant inconsistencies with Prudential’s medical reviewer’s findings. In particular, the appeal addressed Prudential’s unilateral dismissal of the opinions of Ms. L’s highly respected neurologist and infectious disease specialist and its incorrect suggestions that Ms. L’s clinical course was “atypical” and that her constellation of symptoms were “inconsistent” with her documented diagnosis. The appeal also focused on Prudential’s overly restrictive assessment and failure to address whether, regardless of cause, the medical records and treating physician’s medical records support the fact that Ms. L does suffer from debilitating symptoms that prevented her from working, which they clearly did.
Less than one month after filing the appeal, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Prudential overturned its decision to terminate benefits reinstated Ms. L’s long-term disability benefits.