Appellate Court upholds Prudential’s decision denying disability benefits to insured when he refused to attend an IME Exam
Recently, the 8th Circuit Court of Appeals ruled that veteran career consultant, Anthony Polich, was not entitled to Long Term Disability (LTD) benefits after he refused to attend an Independent Medical Exam (IME) and to release relevant medical data requested by the LTD Plan administrator, Prudential Financial.
Polich appealed District Court’s conclusion that Prudential’s requests for an IME and additional medical data were reasonable.
Anthony Polich worked as a veteran career consultant for the State of Iowa from 1997 until 2006 when he resigned after becoming disabled. He was covered by a LTD insurance policy issued to the State by Prudential and on July 20, 2006, an application for benefits was submitted on Polich’s behalf asserting that he was unable to work due to his disability. The application stated that Mr. Polich was suffering from Meniere’s disease – disease of the inner ear – and post-traumatic stress disorder (PTSD). The application also included a statement prepared by a clinical psychologist identifying Mr. Polich’s impairment/limitation as “Cognitive Disorder NOS,” i.e. not otherwise specified, and explaining that Mr. Polich was experiencing dizzy spells, depression, and anxiety.
Prudential denied Polich’s Meniere’s disease disability claim on the ground that he was not disabled.
On October 4, 2006, Prudential denied Mr. Polich’s claim, contending that he was not disabled. Mr. Polich subsequently appealed to Prudential’s Appeal Review Unit who upheld the denial and advised Polich of his right to a second appeal for “a final decision.” Prudential later explained that Polich’s complete appeal had to be submitted by July 12, 2007. After submitting additional materials to supplement his appeal, Polich was informed by Prudential of its arrangement for an independent medical examination (IME).
Polich refused to attend the IME requested by Prudential.
On or about July 11, Prudential arranged for an independent medical exam by a neuropsychologist that Polich refused to attend. Prudential then asked Polich to release the “raw data” on which his physician relied when writing the statement in Polich’s application. Polich again declined to comply and so Prudential had a neuropsychologist review the information already in Polich’s file.
The neuropsychologist decided that the information did not show that Polich had a psychological or cognitive impairment and Prudential thereby concluded that Polich failed to prove that he was unable to work because of Menire’s disease and denied his appeal on the ground that he was not disabled.
District Court granted Prudential’s motion for summary judgment.
After his second appeal was denied, Polich hired an Iowa disability attorney to sue Prudential for breach of the policy. In its defense, Prudential argued that when Polich refused to attend the IME and to release the raw data, he failed to comply with two policy provisions that were required to be eligible for coverage. One provision stated that Prudential could require an insured “to be examined by doctors of its choice as often as it is reasonable to do so, and that refusal to be examined”¦ may result in denial or termination of the insured’s claim.” The other provision provided that “in some cases, the insured will be required to give Prudential authorization to obtain additional medical information, and that Prudential will deny the insured’s claim”¦ if the appropriate information is not submitted.”
Prudential contended that Polich’s claims failed because of his noncompliance and the district court agreed. On those grounds, the court entered judgment in favor of Prudential.
Court of Appeals review of the District Court’s ruling – whether Prudential’s requests were reasonable
Polich appealed to the 8th Circuit Court of Appeals arguing that Prudential’s requests for an IME and additional information were unreasonable. Furthermore, Polich argued that a jury rather than the court should have decided whether such requests were reasonable.
The court of appeals agreed that reasonableness is often a question for a jury, however, where only one reasonable conclusion can be drawn from the undisputed facts, the question can be resolved by the court. After reviewing the decision without bias, the court of appeals concluded that Prudential’s requests for an IME and raw data were reasonable as a matter of law. Accordingly, Polich breached the terms of the Prudential disability policy and was not entitled to disability benefits.