Our client, Mr. T, formerly worked as a Corporate Training Coordinator for a large consumer product corporation. In October 2015 a number chronic psychiatric conditions, including major depressive disorder, major depressive affective disorder, post traumatic stress disorder, chronic anxiety and bipolar affective disorder forced Mr. T to stop working and submit his claim for disability benefits, first under his 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 his employer’s LTD policy, he would be considered totally disabled for the first 12 months if he was unable to perform the material and substantial duties of his “regular occupation” as a Training Coordinator. After 12 months he would be considered totally disabled if he was unable to perform the duties of “any gainful occupation” for which he was qualified by education, training and experience and with additional consideration of his functional limitations and transferable skills.
After paying Mr. T for the maximum 12 month own occupation benefit period under the LTD policy Prudential denied further benefits on the basis that Mr. T allegedly no longer met the policy definition of disability. Specifically, Prudential stated that it “does not find that he has any restrictions or limitations from a psychiatric perspective… and the medical information received did not support impairment that would prevent him from performing material and substantial duties of any gainful occupation.” After receiving the denial, Mr. T contacted Dell & Schaefer and discussed his 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 Mr. T’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Prudential’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 decision to ignore the opinions of Mr. T’s highly respected treating physician, which confirmed that Mr. T suffered from significant psychiatric issues that prevent him from having the functional capabilities to perform all the essential duties of any sedentary occupation with reasonable continuity on a regular and sustainable basis, opting instead for the opinion of a highly compensated physician who, contrary to his own stated practice methodologies, conducted an incomplete paper review and offered an opinion unsupported and contradicted by all the available medical records.
Less than one month after filing the appeal, and after reviewing the appeal letter and hundreds of pages of exhibits and medical records, Prudential overturned its decision to terminate benefits reinstated Mr. T’s long-term disability benefits.