Dell & Schaefer Successfully Appeals Denial of Benefits to Former Director of a Multinational IT Consulting Company
Author: Attorney Victor Peña
Our client, Ms. V, came to us after being denied continued Long Term Disability (“LTD”) benefits by Prudential Insurance Company of America. Ms. V had been receiving LTD benefits for 24 months when Prudential stopped paying her benefits and requested that she undergo an 8-hour psychological evaluation. Ms. V did not understand why Prudential was requiring her to submit to the evaluation when her disability was physical in nature. According to Prudential, Ms. V was depressed and qualified for LTD benefits based on this diagnosis alone. However, while Ms. V was experiencing some level of depression—as would many people who are suffering from a sudden and extreme decline in health— Ms. V was not suffering from disabling depression and had not even been referred to see a mental health specialist.
Ms. V had initially discontinued working due to Chronic Abdominal Pain in addition to headaches and other physical problems. Before going on disability, she was a director of a multinational IT consulting company and had always been a career driven, outgoing, sociable and active person. Following her disability leave, Ms. V’s health declined so much that she could not even perform activities of daily living without the assistance of her husband or mother. Her life became characterized by days where she could not sit up in a chair or in the bed for long periods of time, or even bend, reach or grasp objects due to the chronic pain, joint pain, stiffness, swelling, burning and spasms.
To make matters worse, Ms. V’s doctors had been unable to pinpoint what was causing her multiple physical symptoms despite various tests and evaluations. All of her medical records documented that she was limited by a plethora of physical symptoms including migraines, body aches, pelvic pain, and a gradual development of severe weakness, tremor and inability to ambulate but the origin of her symptomology was unclear.
Prudential terminates Ms. V’s ongoing claim
Under the terms of her employer sponsored disability plan, benefits were payable for a maximum of 24-months for disabilities caused by a mental illness. Although Ms. V had been suffering from a long list of physical symptoms, the presence of which had not been questioned by any of her doctors, Prudential believed Ms. V’s right to continued disability payments was unclear. More importantly, Prudential insisted on focusing on Ms. V’s mental state although she had never submitted a claim for any mental health condition.
The LTD Plan gave Prudential the right to have Ms. V evaluated by a physician of its choice and Prudential chose to exercise that right; but rather than retaining a doctor specializing in pain medicine, Prudential found it appropriate to require Ms. V to undergo a Psychological assessment by a doctor of its choice. According to the doctor’s report, the test was designed to measure mental and emotional status, effort, validity, word reading, intelligence and memory. Frustrated with Prudential’s request, Ms. V insisted that she was not anxious or depressed, and that she never had psychological problems and that psychological problems do not adversely impact her functioning.
Unsurprisingly, the test was deemed invalid. Interestingly, the same doctor’s report noted observations regarding Ms. V’s physical problems—although this was outside the doctor’s medical specialty—and suggested that Ms. V may have conversion disorder. (Conversion disorder is a condition in which you show psychological stress in physical ways). In other words, the doctor suggested that Ms. V’s physical symptoms were “all in her head” and due to a psychiatric disorder.
Based on the results of the psychological assessment—and on the opinion of Prudential’s neurologist who stated that the only plausible explanation for Ms. V’s overall functional capacity appears to be the presence of a possible Conversion Disorder—Prudential terminated Ms. V’s claim concluding that she was disabled due to a mental health condition and therefore benefits were payable for a maximum of 24-months.
Appeal by Attorneys Dell & Schaefer
Ms. V contacted Attorneys Dell & Schaefer and discussed her claim with Attorney Victor Peña. After reviewing the claim and discussing Ms. V’s medical history, it became apparent that Prudential had made many errors.
Attorney Peña and his team immediately began working on Ms. V’s claim. After reviewing the claim file it was clear that Prudential had, from the beginning, grouped Ms. V’s claim into a mental health category, despite the absence of any evidence of a disabling mental health condition. Various claim notes focused on a psychogenic view to explain Ms. V’s various physical conditions. Due to the atypical and complex nature of Ms. V’s complaints and the absence of a firm diagnosis to explain Ms. V’s symptom complex, Prudential and its various doctors constantly questioned Ms. V’s credibility. Prudential did not believe Ms. V was actually suffering from her physical conditions and so did everything it could to elicit evidence that Ms. V’s disability was merely a mental health condition.
More importantly, Prudential and its doctors completely overlooked or ignored the fact that, among the various diagnoses identified by her different physicians, was a diagnosis of RSD or Reflex Sympathetic Dystrophy, otherwise known as CRPS (Complex Regional Pain Syndrome).
Prudential had failed to notice that a diagnosis of CRPS explained all of Ms. V’s symptomology. Moreover, Prudential had failed to have an independent doctor certified in Pain Management review Ms. V’s medical records before making the decision to terminate her benefits. Instead, Prudential chose to focus on a psychogenic explanation for Ms. V’s disability and concluded that Ms. V’s disability was all in her head. Prudential’s request that Ms. V undergo a psychological evaluation was simply an attempt to create more support for its theory that Ms. V’s disability was psychogenic in nature. This was easy for Prudential to do when Ms. V was suffering from a condition that is often misdiagnosed by doctors as a mental illness.
Complex Regional Pain Syndrome is a neuropathic disorder that usually occurs after a trauma, surgery, medical procedure, prolonged immobilization. 1 CRPS I is characterized by intractable pain that is out of proportion to the trauma, and CRPS II is characterized by unrelenting pain that occurs subsequent to a nerve injury. 2 The criteria for diagnosing CRPS is abstruse due to the vast spectrum of disease presentation and can include, but is not limited to: intractable pain out of proportion to an injury; intense burning pain; pain from non-injurious stimulation; an exaggerated feeling of pain; temperature changes in the affected body part; edema; motor/trophic disturbances; changes in skin, hair, and nails; and abnormal skin color. 3 These symptoms often begin in a limb of CRPS I patients and spread bilaterally or systematically to adjacent limbs. 4 Many healthcare providers are not familiar with the presentation of CRPS and, although the disease may be under reported, more than 50,000 new cases of CRPS I occur annually in the United States. 5
It is suspected that a significantly large number of cases of CRPS are being misdiagnosed by health care providers and being attributed to psychogenic issues.
Unfortunately, Prudential and its physicians failed to look further into Ms. V’s diagnosis of CRPS. Attorney Peña and his team focused the appeal on showing Prudential that Ms. V’s physical conditions were real and severely debilitating. The appeal included the results of a Functional Capacity Evaluation (FCE) which provided additional objective evidence validating the existence of Ms. V’s functional limitations. Most importantly, the appeal focused Prudential’s attention on the diagnosis of CRPS and provided detailed medical literature educating Prudential on its improper characterization of Ms. V’s claim. The existence of Ms. V’s physical ailments could not be questions and Prudential had failed to give Ms. V’s claim proper consideration.
On Appeal, Prudential requested that Ms. V undergo another Independent Medical Evaluation (IME). This time, the IME was scheduled with a doctor certified in Pain Medicine and Rehabilitation. After being forced to perform a proper review of Ms. V’ claim, Prudential eventually realized its initial decision was in error and agreed to overturn its decision.
Ms. V’s monthly disability benefits have been reinstated and she continues to be represented by Attorneys Dell & Schaefer.
1 Bruehl S. An update on the pathophysiology of complex regional pain syndrome. Anesthesiology. 2010; 113(3): 713-25.
2 Bruehl S. An update on the pathophysiology of complex regional pain syndrome. Anesthesiology. 2010; 113(3): 713-25.
3 Harden RN, Bruehl S, Stanton-Hicks M. Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med. 2007; 8(4):326-31. Doi: 10.1111/j.1526-4637.2006.00169.x.
4 Bruehl S. An update on the pathophysiology of complex regional pain syndrome. Anesthesiology. 2010; 113(3): 713-25.
5 De Mos M, de Bruijn AG, Huygen FJ, Dieleman JP, Stricker BH, Sturkenboom MC. The incidence of complex regional pain syndrome: a population-based study. Pain. 2007; 129(1-2):12-20. Doi:10.1016/j.pain.2006.09.008.
Read more about Complex Regional Pain Syndrome disability claims.