California Court Overturns Prudential Denial of LTD Benefits

In reviewing long term disability denial letters we find that there are a handful of industry wide arguments made by insurance companies to minimize the nature of one’s occupation. The most common being the downplaying of the cognitive demands of a given occupation in favor of focusing solely on the physical demands of the occupation. This often occurs when (1) the nature of the disability is due to a medical condition related to or caused by physical pain complaints and (2) the pre-disability occupation is at an “executive” level requiring higher levels of cognitive functioning- such as engineers, financial analysts, attorneys, corporate workers, doctors, etc.

Occupations such as the above typically fall within the “Sedentary” physical demand level as determined by the Department of Labor. However, anyone who works in an occupation that essentially pay them for the ability to think know that the actual “material and substantial” or “essential” duties of the job go far beyond the ability to sit and lift a negligible amount of weight frequently (i.e. do Sedentary work). In high functioning jobs the essence of the occupation is the ability to be cognitively sharp, detail oriented, analytical or basically get paid for your ability to think. For anyone who suffers from a chronic pain condition – be it back, neck, musculoskeletal pain, migraines or chronic headaches that affects their daily lives – it is only to be expected that one’s cognitive abilities will suffer on account of the pain. After all, it is very hard to concentrate when you’re in severe pain. However, insurance companies reviewing claims for short or long term disability historically ignore this common sense fact and seek to argue that the ability to work at a Sedentary level means one can do their actual occupational duties.

In a recent federal court ruling from the United States District Court for the Central District of California, Bowlin v. The Prudential Life Insurance Company of America, the Court addresses a situation where one’s physical medical conditions, in this case chronic daily headaches, impair one’s cognitive abilities. After hearing arguments from both sides, the Court ultimately overturned Prudential’s denial of Bowlin’s claim and in doing so determined that the evidence provided by Bowlin supported the fact that the severity of her medical symptoms would prevent her from performing the cognitively demanding duties of her pre-disability occupation.

Prior to filing for long term disability Bowlin worked for J.P. Morgan Chase as a relationship manager responsible for a multitude of complex duties, which the Court notes to include: “meet with high net-worth clients, conduct presentations, build collaborative relationships, manage and grow a portfolio of clients, manage credit opportunities, review voluminous financial information, use her knowledge to identify, promote, and recommend products and solutions to best serve clients, build and utilize referral networks to independently identify and pursue potential new clients, follow sound risk-management protocols, and develop and manage a disciplined marketing process.” Due to multiple medical conditions, to include chronic headaches, Bowlin ceased working at the recommendation of her doctors and filed a claim for long term disability benefits under Chase’s disability policy with Prudential. As is often the case, Prudential’s review of Bowlin’s medical records only involved paper file reviews by medical professionals hired by Prudential. The medical reviews performed by Prudential focused on what the doctors deemed was a lack of objective medical evidence to support restrictions and limitations that would prevent Bowlin from performing her Sedentary job duties. This argument perpetuated the review of her claim despite the fact that by the nature of her medical condition (chronic headaches) there was not objective medical evidence that could be provided to support her subjective complaints of pain. Despite doctor support based on clinical evaluation that her conditions were impacting her ability to meet her occupational requirements, Bowlin’s claim was denied by Prudential on application and through the administrative appeal process.

The Lawsuit

One of the key factors in Bowlin’s success against Prudential in court was the fact her claim and action originated in California. Unlike the majority of jurisdictions and states, California employs a de novo standard of review at trial, which means the Court is tasked with only determining whether or not the plaintiff/insured has proved by a preponderance of the evidence that he or she is disabled under the terms and conditions of the LTD plan. This is in stark contrast to the majority of jurisdictions that utilize an arbitrary and capricious standard of review in which the Court has to grant deference to the review performed by the insurance company as to the reasonableness of same. As such, the opinion of the Court in Bowlin would not apply to every insured similarly situated. However, the opinions of the Court provides argument that an insured could make to his or her disability insurance carrier and/or Court.

The Court noted in its opinion that due to the fact the Policy provisions focused on the Plaintiff’s ability to perform the material and substantial duties of Bowlin’s occupation with Chase, her entitlement to benefits should be measured by her functional capacity and therefore “reasoned assessments” of what Bowlin can and cannot do are to be given more weight than mere statements of medical diagnoses. The Court expanded on this rationale and stated that descriptions of her symptomology are therefore more helpful in determining her ability for work than the medical diagnoses alone. Finally, the Court recognized that certain disabling conditions are not able to be substantiated through objective medical evidence, and that ERISA governed disability plans could not deny benefits by requiring such evidence where it does not exist. Although the Court was speaking as to Bowlin’s headache condition, it also referenced that this would also apply to conditions such as chronic fatigue or fibromyalgia.

Within the context of the above the Court evaluated both the information provided by Bowlin during the course of her claim and that created by Prudential during the course of its review. Due to the nature of the de novo review used in this case the Court was able to provide deference to the opinions of Bowlin’s treatment providers, who had physically examined Bowlin, as opposed to Prudential’s reviewing medical professional who simply performed reviews of her file. Based on the information in the claim file the Court determined that Bowlin was disabled under the Prudential policy as the evidence supported that due to her medical conditions Bowlin did not have the cognitive abilities to perform her occupational duties. The Court in this case awarded benefits to Bowlin for a period of time leading up to the date her doctors indicated she would be able to return to work.

In rendering this opinion the Court effectively rejected Prudential’s argument that Bowlin was not disabled due to her ability to work at a Sedentary demand level. The Court looked beyond the physical requirements and focused on the cognitive demands of the occupation to determine disability.

Are your physical pain conditions impacting your ability to perform the cognitive duties of your occupation?

Although the above stated facts surrounding the Bowlin case would not universally apply to all claims for disability similar in nature, the Court’s findings do provide arguments as to how an insurance company should be reviewing a claim for disability in light of (1) one’s medical conditions and (2) the actual demands of the occupation.

Our office did not represent Bowlin in the above case. However, we report on cases that can prove to be helpful to anyone who has a disability insurance claim. If you have questions regarding your disability insurance claim, please feel free to contact our office to speak to one of our disability attorneys.

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