In the case of Gallegos v. Prudential, a California Federal District in the Northern District of California entered an order instructing Prudential to reinstate the benefits to an insured suffering with Lupus. This ruling provides a plethora of useful information in arguing claims for disability stemming from Lupus, but also for any physical medical condition in which an insurance carrier argues a “lack of objective evidence” to support disability.
Prior to filing for disability Gallegos worked as a drug safety operations manager for a pharmaceuticals company in California. She initially filed a claim for disability due to severe headaches with associated altered vision, but was able to return to work after a brief period of short term disability. However, as luck would have it, within a few months of her return to work she had to undergo rotator cuff surgery, necessitating another disability claim. Following surgery and recovery she attempted to return to work, but after just six months she was forced to file another claim for disability due to persistent headaches and fatigue, which would later be diagnosed by her doctors as Lupus. Prudential initially approved her claim for short term disability benefits and then her claim for long term disability benefits after short term benefits ceased. However, her approval of her LTD claim was predicated on the results of her next office visit with her doctor. Once the records from the visit were received, Prudential had a paper file review of her claim performed by an outside doctor. Unsurprisingly, the opinion of the reviewing doctor resulted in the denial of Gallegos’ claim for LTD benefits.
In furtherance of appealing the denial of benefits, Gallegos underwent a Functional Capacity Examination, the results of which indicated she did not have the ability to perform the physical demands of her occupation. She then had her file reviewed by an independent Vocational Consultant, whose report provided additional support that based on her medical conditions and the demands of her pre-disability occupation Gallegos would not be able to meet the required demands of her occupation. Additionally, during the course of her first appeal, following an independent medical examination by the Social Security Administration that verified cognitive limitations stemming from her diagnosis of Lupus, Gallegos was awarded Social Security disability benefits.
In response to Gallegos’ appeal Prudential sent her file to be reviewed by two independent doctors (rheumatology and neurology) for the purposes of conducting additional paper reviews. Despite staunch support from her treating neurologist, Prudential’s reviewing neurologist found no evidence disability from a neurological viewpoint. The reviewing rheumatologist, having admitted she did not review the entire file, opined that she did not believe there was sufficient evidence to establish a diagnosis of Lupus. Prudential essentially ignored the information provided on appeal and instead relied on opinions of its two hired file review doctors to deny Gallegos’ appeal.
In response to the denial of her appeal, Gallegos availed herself of the voluntary appeal process and provided Prudential, amongst other medical records, with abnormal lab results, which objectively identified a positive test result for Lupus. The positive test results would certainly undermine the opinion of Prudential’s reviewing rheumatologist who had found no evidence to support a diagnosis of Lupus. Nevertheless, Prudential provided the updated medical information for review to the same two doctors who denied her first appeal. Even when faced with objective proof of the Lupus, Prudential’s doctors questioned the validity of the testing and held true to their initial opinions that there was no indication of medical restrictions and limitations that would necessitate disability.
Following the final denial of benefits Gallegos filed suit under ERISA. Fortunately for Gallegos the Judge saw her claim much differently than Prudential and overturned the denial of benefits. In rendering its opinion the Court noted several key factors as to why it believed Prudential was wrong in denying Gallegos’ benefit. The Court determined that while Prudential’s prior approval of disability did not shift the burden back to Prudential to provide proof as to why disability was no longer supported, the Court did find that the earlier decision to approve LTD benefits was relevant and Prudential’s failure to identify a significant change in Gallegos’ condition was a factor to be considered. The Court also noted that the consistent opinions from Gallegos’ treatment providers presented a persuasive case for disability and that Prudential had given no meaningful weight to their examinations and opinions. The Judge also stated that the FCE was not given proper consideration by Prudential’s doctors and that the findings of the examination were probative and deserving of “valued consideration” by Prudential. With regards to the test results indicating a diagnosis of Lupus and Prudential’s attempt to discredit same, the Court noted that while a lab test alone would not establish disability, when considered in conjunction with other evidence in Gallegos’ claim file – such as the FCE and opinions of her treatment providers – the Court found no basis for Prudential’s disregard of her symptoms as self-reported and denial of her claim. Furthermore, speaking as to the nature of Lupus, the Court added “Because Gallegos might be stable at various points does not mean that the debilitating symptoms will not be exacerbated if she return to work on a full time basis.”
This Court decision provides much valuable information in presenting disability claims resulting from Lupus and will hopefully serve as a gateway for more Courts scrutinizing and rejecting the tactics employed by insurance companies when denying disability insurance claims due to Lupus.