Dell & Schaefer Refuses to Allow Prudential to Force Claimant Into Submission

A recent denial overturned by Prudential illustrates the value of having an attorney manage your claim for you in the long run.

Since March 31, 2012, Ms. V has been unable to perform the material and substantial duties of her regular occupation or any occupation. Benefits were initially paid to Ms. V due to her debilitating pain; however, almost immediately, Prudential began its attempts to categorize Ms. V’s claim in some way to limit its liability under the policy. In 2013 Prudential sent a letter to Ms. V with policy language explaining that her claim could end at the 24 month mark. The letter seemed to imply that Ms. V’s claim could be subject to the 24-month mental illness limitation in her policy. Up until that point, neither Ms. V nor her doctors had indicated that Ms. V was disabled by any mental health condition. Despite this fact, Prudential found it appropriate to have Ms. V undergo a psychological evaluation. While Prudential also requested a file review by a doctor in neurology, it did not request a physical evaluation of Ms. V despite her suffering debilitating physical pain.

Ms. V came to us in 2014 for assistance with fighting Prudential. At the time, her claim was being paid but Prudential insisted that her claim, although based on functional deficits caused by physically disabling medical conditions, was subject to the Plan’s 24-month mental nervous limitation.

Prudential’s first improper denial of benefits

In January 2015 Prudential provided notification of its decision to terminate Ms. V’s claim under the mental health limitation of her policy relying on statements from its hired psychologist, Dr. Richard Gelb that there appears to be the presence of a possible Conversion Disorder (Conversion disorder is a condition in which you show psychological stress in physical ways). An appeal was prepared by this office which included substantial evidence that Ms. V’s condition is adequately explained by the diagnosis of Complex Regional Pain Syndrome (CRPS), a condition which had been diagnosed but had been, up until that point, completely ignored by Prudential and its hired physicians. The appeal included a valid Functional Capacity Evaluation and several supportive statements from doctors. Additionally, the appeal included a very detailed pain journal. After a long appeals process, our office was successful in getting her claim reinstated based on her primary disabling condition of Complex Regional Pain Syndrome (CRPS). See this article.

Since then, our client’s condition has not improved and she has had numerous hospital visits, each time seeing new physicians who struggle to fully understand her often misunderstood medical condition. Although her medical records continue to document her many disabling symptoms it seems Prudential does not want to continue paying her claim. At only 45 years old, there is nothing to suggest that our client’s condition is expected to improve at any point in the near future and Prudential could be on the hook for another 20 years of benefits if doctors don’t find a way to effectively treat our client’s misunderstood medical condition.

However, Prudential never stops looking for a way to limit its liability on this claim. In August 2017 Prudential sent a letter to our office with notification that it had scheduled another “independent” evaluation by none other than Dr. Richard Gelb. In the same letter Prudential quoted policy language regarding its right to require such examinations and that refusal to be examined could result in denial or termination of the claim.

Attorney Peña responded with a letter requesting an explanation on why Prudential was requesting the same evaluation with the same doctor that supported the previously overturned denial of benefits. A request was also made for a videographer to be present and a demand that Prudential schedule an appointment with a doctor of the correct medical specialty if an examination was truly necessary. Naturally, the request for a videographer was denied.

So as not to give Prudential an easy way to deny the claim Ms. V attended the neuropsychological evaluation administered again by Dr. Gelb. During the evaluation, Ms. V had a flare up of her condition and suffered extreme swelling in her extremities. Her hands became purple from the simple task of filling out doctor forms. Unsurprisingly, Dr. Gelb’s report failed to include an adequate description of Ms. V’s symptomology. However, at Attorney Peña’s request, Ms. V’s family was able to document the symptoms with date stamped pictures on their phones.

Prudential terminates the claim again

As if Prudential had completely forgotten about its previously overturned decision years prior, Prudential sent notification in December 2017 that it was terminating Ms. V’s claim based on Dr. Gelb’s opinion which almost mirrored his opinion written years prior.

Attorney Peña and his team began immediately working to tear apart Prudential’s obvious attempt to reclassify Ms. V’s condition as a mental health condition. The appeal included pictures documenting Ms. V’s symptoms the day of Dr. Gelb’s evaluation. Attorney Peña also demanded that Prudential set up an evaluation by a doctor previously used by Prudential who supported Ms. V’s claim years before. After all, it would only be fair since Prudential found it reasonable to utilize the same doctor it had relied on in the past who had supported the previous denial of benefits.

At the very least, Prudential should schedule an evaluation with a doctor who specialized in pain medicine. Shortly after the request was made, Prudential notified our office that an independent medical evaluation would be scheduled with a pain specialist and the doctor would comply with our request that a videographer be present to record the evaluation.

The video was submitted to Prudential to ensure it became part of the administrative record. Also submitted to prudential were photos documenting Ms. V’s symptoms and medical records from an urgent care visit that was necessary following the evaluation as a result of the stress put on Ms. V’s body.

The appeal demanded immediate reinstatement of Ms. V’s claim and that Prudential should abstain from performing anymore unnecessary evaluations by doctors who are not of the appropriate medical specialty.

Shortly after, our office received a long letter from Prudential outlining their decision to reinstate Ms. V’s disability claim.

This claim is a perfect example of how insurance companies never rest in trying to limit their liability on a claim. Prudential had no shame attempting to use exactly the same reason and exactly the same doctor as it used to deny the claim before. It seems that Prudential was hoping that Ms. V would give up fighting, which is what many claimant do in her position.

If you have a similar claim against Prudential please do not hesitate to contact our office for a free consultation.

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FAQ

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We represent Prudential clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Prudential disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Prudential. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Prudential.

How do you help Prudential claimants?

Our lawyers help individuals that have either purchased a Prudential long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Prudential:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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Dell & Schaefer Client Reviews   *****

Noah P.

A few years ago I found myself unable to work and needing treatment. While I was getting the treatment I needed my employer fired me. This left me still needing treatment as well as needing to find a source of income. Not knowing where to turn or what to do my wife an I contacted Dell & Schaefer for help. Upon speaking with attorney Stephen Jessup we felt assured that we had found the help we needed. Attorney Jessup worked with the attorneys from my former employer and explained my situation to them. During the weeks of negotiations attorney Jessup kept us informed as to the progress and ultimately called us with a settlement offer. We were so relieved and grateful!

But that is not where our story ended. After informing us of the offer presented by my former employer, attorney Jessup advised me that he felt he could get us a better settlement with just a bit more time. I discussed it with my wife and we both felt confident in attorney Jessup’s advice so we allowed him to further negotiate on our behalf. Sure enough, a more equitable settlement was reached in a very short time. During the entire process attorney Jessup and the staff at Dell & Schaefer handled everything with very little input needed from us. This allowed me the time and reassurance that I needed in order to heal. Their professionalism and reassuring manner never left me feeling concerned that I wasn’t being fully represented despite the fact that they rarely needed participation directly from me. In the end my confidence in them was rewarded with a better settlement than I was expecting. My wife and I are forever grateful. From my experience it would be very difficult for Dell & Schaefer to improve upon their process.

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