Dell & Schaefer Successfully Appeals Denial Of Benefits To Former Trial Attorney
Author: Attorney Victor Peña
Gastrointestinal issues are very common and often conditions that people don’t like to discuss in detail. They are also often downplayed by disability carriers as conditions that are not disabling as long as the claimant can take bathroom breaks. Insurance companies will regularly ignore the secondary issues that come along with having even minor gastrointestinal problems.
One of our clients recently contacted us after receiving a denial letter from her disability carrier, Prudential Insurance Company of America. Prudential had concluded – based on a paper file review by a doctor Board Certified in Gastroenterology – that Ms. E had the ability to work as long as she could take bathroom breaks.
Unfortunately, Prudential and its reviewing doctor had grossly underestimated the debilitating nature of Ms. E’s condition.
Ms. E, a senior trial attorney for a large company, was forced to stop working due to Stage III Rectal Cancer for which she underwent a partial resection and chemotherapy and radiation. The treatment, while successful, left her suffering from chronic Radiation Enteritis as well as cognitive limitations resulting from the chemotherapy – a common condition known as chemo brain.
As a very successful attorney with a lot of experience handling complex cases Ms. E took on the task of handling her own administrative appeal with Prudential. After several months she realized that handling the appeal on her own was an overwhelming task when at the same time she was suffering from chronic debilitating medical conditions. She was having a hard time sifting through the over 2,000 page claim file provided by Prudential and could not understand how Prudential could have denied her claim.
As the deadline drew closer she realized she could not handle the appeal on her own so she contacted our firm and spoke with Attorney Victor Peña. During the first call it became clear to Attorney Peña that Prudential had improperly denied Ms. E’s claim. However, there were only three weeks remaining before the appeal was due.
Despite the limited time frame, Attorney Peña agreed to take on the case and he and his team immediately began working on the case.
Prudential had relied primarily on a paper file review by a gastroenterologist who downplayed the very severe symptoms suffered by Ms. E as a result of her Radiation Enteritis. It was clear that Prudential had to be made aware of their gross underestimation of the effects from this debilitating condition. What’s more, Prudential had completely ignored the well documented cognitive limitations suffered by Ms. E that prevented her from returning to work in her occupation or any occupation for which she was reasonably qualified.
Attorney Peña and his team quickly gathered the medical records that could be assembled in the limited time frame and reviewed the deficiencies in Prudential’s review. The team was able to elicit several responses from treating physicians in time to submit the appeal to Prudential.
Within two weeks of submitting the appeal, a faxed letter was received from Prudential overturning the denial – one of the fastest decisions seen from Prudential on Appeal. Apparently, Prudential had another gastroenterologist review the same file – along with the evidence generated during the appeal including the responses elicited from the treating physicians. This gastroenterologist recognized the severity of our client’s condition and provided a report attesting to that.
Based on the appeal and the new doctor’s opinion report, Prudential has reinstated our client’s claim and will continue to pay benefits.
This claim is a perfect example of how easy it is for an insurance company to downplay the disabling nature of a condition related to gastrointestinal issues. Chronic Radiation Enteritis can be a severely debilitating condition that would affect anyone’s ability to work, regardless of the occupation.
If you have a similar claim with Prudential or any other disability insurance company please feel free to contact our office for a free consultation.