Court Finds Prudential Abused its Discretion in Denying LTD Benefits
Author: Attorney Cesar Gavidia
In James Ampe v. The Prudential Insurance Company of America, et al., Plaintiff Ampe worked for several years for the Massachusetts Institute of Technology (MIT) as a senior development and test engineer. In August 2011, Ampe slipped and fell in his bathroom, hitting his head.
He noticed some cognitive decline over the next few months and took intermittent FMLA leave. Meanwhile, his performance reviews deteriorated. The 2014 review was so bad that MIT told Ampe he needed to apply for long-term disability (LTD) benefits since it would no longer provide him any work accommodations.
Ampe’s initial claim was denied. He filed two administrative appeals, and his claim was still denied. After exhausting his administrative appeals, he filed this ERISA lawsuit.
The United States District Court for the District of Massachusetts held there was no substantial evidence to support Prudential’s denial and therefore, the denial was an abuse of discretion. The Court remanded the case back to Prudential to reconsider its denial consistent with the Court’s opinion.
Prudential Abused Its Discretion by Relying on The Report of One Reviewing Consultant
Ampe presented medical records from “three examining specialists and a treating physician” who reported that Ampe could not perform his job due to a diagnosis of post-concussion syndrome. Tests showed he was cooperative and tried his best, but had significant cognitive losses and was not “malingering.” He was granted disability benefits by the Social Security Administration (SSA), so he submitted to Prudential the report from SSA’s independent medical examiner who agreed with Ampe’s treating physicians that Ampe had significant cognitive losses.
Prudential had the file reviewed by its own doctor who discounted medical literature submitted by Ampe’s physician to support the diagnosis of post-concussion syndrome. The Court noted that, although not overt, the reviewing doctor, who had never examined Ampe, clearly was under the “conviction that Ampe was a malingerer.”
The Court concluded that although it could not determine “in any definitive fashion the medical validity of post-concussion syndrome as a diagnosis, there is enough support in the medical literature documenting its existence so as to make a denial of LTD benefits based on one skeptical doctor’s file review open to question, especially where three examining specialists and a treating physician at different times came to a contrary conclusion.”
Prudential Failed to Determine if Ampe’s Conceded Limitations Interfered with the Demands of his Occupation
The Court noted that Ampe’s complaints of severe headaches and fatigue were not addressed by Prudential’s file reviewer who even said that those symptoms were “outside her area of expertise.” Prudential never addressed how these symptoms might affect Ampe’s job performance. In the administrative record, there was no evidence that Prudential engaged in any analysis about whether Ampe’s symptoms, whether subjective or substantiated by objective testing, had an impact on “his ability to perform the work of a Senior Development and Test Engineer.” This failure showed that Prudential abused its discretion in denying LTD benefts.
Remand is the Remedy
When a court finds a claims administrator abused its discretion, the remedy is either to award benefits, or remand to the administrator for further proceedings. In this case, the Court determined that remand for “a more considered examination of the medical evidence” was the proper remedy.
This case was not handled by our office, but we feel it can be instructive to those who are having problems with their disability claim. For questions about this case, or any matter having to do with your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.