Wisconsin disability attorney and client sue Prudential Life Insurance for its “baseless” denial of ERISA disability benefits

Claiming that Prudential violated ERISA by improperly refusing to pay entitled disability benefits under her long term disability and life insurance policy, Della Davis and her Wisconsin disability attorney filed a complaint against Prudential.

In the compliant which was filed in the United States District Court of the Western District of Wisconsin, Davis and her Wisconsin disability attorney request that the court:

Documented Medical Records Confirm Disability Attorney’s Client’s Disability

Diagnosed with various medical conditions, including “cervical radiculopathy, cervicalgia, herniated disks, degenerative disc disease, spondylosis and osteoarthritis, foraminal stenosis, chronic thoracolumbar strain, degenerative changes in the lumbosacral spine, fibromyalgia, bilateral carpal tunnel syndrome (CTS), right shoulder pain with impingement syndrome, deltoid atrophy, arthritis of the left knee, sleep apnea, chronic fatigue syndrome, vertigo/imbalance disorder, and thoracic outlet syndrome,” Davis repeatedly appealed Prudential’s denial of her disability benefits. In fact, even in the face of overwhelming medical documentation and proof of Davis’ many attempts at treatment, Prudential informed Davis in its May 16, 2006 denial letter that, “she could self-accommodate for the CTS” and that “no severity of symptoms objectively supported with diagnostics relating to the other medical conditions” were considered severe enough to prevent Davis from functioning in a sedentary position.

Appealing many times to Prudential to reconsider her claims and award her disability benefits from 2006 through 2011, Davis has now exhausted her administrative appeals and has been forced to retain a Wisconsin disability attorney to argue her case. Employed with the Detroit Area Agency on Aging (DAAA) as a Pre-Screener since October 2001, Davis stopped working on March 22, 2006 when after numerous tests, treatments and attempts to remedy her medical problems, she was unable to sit for prolonged periods of time. On April 5, 2006, Davis filed a Group Disability Insurance Employee Statement (“Disability Statement”) with Prudential to apply for her disability benefits. Davis’ Disability Statement informed Prudential that she was disabled by Fibromyalgia “a chronic disease that is aggravated by stress, exhaustion and other factors. When aggravated it causes extreme pain, exhaustion [and] muscle weakness.” Along with her claim, Davis provided Prudential with an Attending Physician Statement from her treating physician verifying her condition but Davis was denied short term disability benefits.

On May 22, 2006, Davis’ physician informed Prudential that “on serial physical examination,” Davis was found to have profound limitations due to her physical conditions and that the medication she takes causes sedation and a lack of alertness. Consequently, Davis appealed the denial of her short term disability benefits based on her physician’s statements , continued in therapy, had other testing conducted and was proclaimed to be “totally incapacitated”; after which, Prudential overturned its earlier decision and granted Davis her short term disability benefits on July 13, 2006. Davis continued to see her physicians, supplied Prudential with her progress or lack thereof, and was awarded long term disability benefits on September 8, 2006 that became effective on September 19, 2006.

On September 8, 2006, “Prudential required Ms. Davis to apply for Social Security Disability Income (SSDI).” Consequently, in December 2006, the Social Security Administration (SSA) determined that Davis was disabled from working at any job and awarded her disability benefits. Then, around November 22, 2006, Prudential informed Davis that for her life insurance benefits to continue without her requirement to pay the premiums, she would have to remain totally disabled. And, in December 2006, SSDI did indeed declare Davis totally disabled and awarded her retroactive SSDI benefits back to September 2006. As a result of the SSDI award, Prudential immediately demanded that Davis repay Prudential $1,310.28 for overpaid to her of long term disability benefits.

Continuing to see her doctors in an attempt to alleviate the debilitating pain of her various conditions, Davis’s condition did not improve, and she was subsequently diagnosed with several other complications that required injections, pain medications, and therapy, none of which worked very well. With ample documentation of Davis’ years of ongoing medical evaluation and treatment, Prudential informed Davis in November 2007 that her claim for long term disability was under review. After requiring Davis to undergo an Independent Medical Evaluation (IME) with the evaluator’s notes that stated “there were no objective findings to support your inability to perform activities,” Prudential terminated Davis’ long term disability benefits in February 2008. Consequently, her group life insurance policy was discontinued as well.

Davis continued her doctor’s visits, underwent surgery on her right shoulder, attended physical therapy, and filed an appeal with Prudential. And, on December 10, 2008, Prudential reinstated Davis eligibility for additional long term benefits and reinstated her claim, informing Davis that it had determined that Davis is “currently disabled from performing any gainful occupation.” In Janurary2009, Davis inquired as to why Prudential had not responded to her appeal for continuation of her group life insurance benefits and that benefit was also reinstated.

Prudential’s Denial of Long Term Disability Benefits Based on a One-Hour IME

In its ongoing quest to deny Davis her disability benefits, Prudential required Davis to undergo an IME evaluation, a “cursory examination that lasted less than one (1) hour.” In the doctor’s report, he contradicted himself by stating in one portion of his report that Davis “has good communication and cognition skills” and then stating, “She is not a very good historian and has difficulty recalling recent events” and has “memory difficulty.” In contradiction to Davis’ treating physicians opinions, the IME evaluator ignored many of Davis’ conditions and did not properly give weight to her symptoms, diagnoses and treatment outcomes and opined that Davis was capable of working. Davis’ long term disability benefits and her life insurance benefits were terminated as a result of this one-hour evaluation.

Evidence is Lacking in Support of Prudential’s Denial of Client’s Disability Benefits

With documentation upon documentation of Davis’ disabilities, video surveillance that verified her severe problems, and numerous diagnostic tests confirming those problems, Davis supplied Prudential with an Affidavit of her condition on February 11, 2010 to no avail. In addition, on February 18, 2010, Davis’ physician noted that Davis now suffers from borderline Adult Onset Diabetes Mellitus (AODM) in addition to her other painful conditions. Again Prudential denied Davis’ April 2010 appeal stating that it attributes Davis’ “conditions/impairments to behavioral or psychological conditions.” Completely disregarding Davis’ medical documentation of physical problems, Prudential stated in its denial letter that “Ms. Davis is a somatoform which means that she tends to express emotional discomfort in physical symptoms, that she tends to over-perceive and over-express her symptoms relative to the majority of people in the society, and that she probably has had such a tendency all her life.” None of Davis’ medical records referred to Davis as having any mental or psychological problems except in reference to the effects of medication causing some sedation effects.

In their complaint, Davis and her disability attorney, allege that Prudential’s evaluation of Davis “is completely baseless.” A case of extremely differing takes on the same information, this court appearance should prove to be an interesting battle between Davis and her Wisconsin disability attorney and Prudential.

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There are 2 comments

  • Barb,

    Your concerns are valid. There is no US Department of Insurance. There is a Department of Labor which can enforce ERISA violations but they are understaffed and overwhelmed. Each state has their own Department of Insurance and these departments can put pressure on disability insurance companies that act unreasonably. The disability industry claims that they approve more than 70% of the people that apply for disability insurance. By being aware of the scrutiny that you could face, then you will have a much better chance of avoiding problems with your disability company. If we can assist you, then give us a call.

    Gregory DellMar 3, 2012  #2

  • After reading this article, I have extreme concerns regarding my recent post regarding my Prudential Long Term Disability and SSDI. I am the sole support of my self and my disabled over-21 years old son. I am already in financial debt including medical and personal finances. To read the many people that are having to engage attorneys to their entitled rewards causes my head to spin. Why hasn’t the U.S. Department of Insurance taken issue with repeated claims against disability insurance companies?

    BarbMar 3, 2012  #1

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