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LTD Claim Approved for a Second Time for an Insurance Sales Agent after Prudential Denies Claim Based on Self-Reported Physical Capabilities

Attorney Alex PalamaraAuthor: Attorney Alex Palamara

Despite Prudential’s numerous attempts to deny our client her long term disability benefits, Attorney Alexander Palamara was able to successfully identify the egregious mistakes in Prudential’s newest reviews and this resulted in Prudential’s second decision to overturn a denial on this claim. Our client once again has ongoing and current payments of long term disability benefits which she has received since 2012.

Our client suffers from numerous physical ailments, but was originally forced to stop work as an insurance sales agent in 2014 due to Sjogren’s syndrome and optic neuritis. Our client also suffers from Fibromyalgia, Arthralgias, Persistent Headaches, Fatigue, Vertigo, Cervical Degenerative Joint Disease, Neck Pain, Joint Pain, Lumbar Spine Scoliosis, Rheumatoid Arthritis, Profound Paresthesias, Bilateral Knee Pain, Bilateral Metatarsal Phalangeal Pain, Essential Hypertension, Cognitive Decline and Dysfunction, Moderate Mood Disorder and Mild Anxiety Disorder.

Despite all of these diagnoses and full support by multiple treating physicians, Prudential continuously attempted to deny our client’s claim and terminate long term disability benefits.

Denials By Lincoln, Appeals by Attorney Palamara

In its first denial letter of 2014, Prudential stated that after “a thorough evaluation of the information in your file, we have determined that you do not meet the definition of disability…”. Prudential stated that it had “determined that the information in (her) file does not support impairment that would prevent (her) from performing material and substantial duties of (her) own occupation.” As such, Prudential terminated her claim. Unable to grasp how her claim could be denied in light of her physical condition, our client found Dell & Schaefer to assist her with an appeal to challenge the wrongful denial. Attorney Alexander Palamara reviewed the claim and agreed that there was no question she should be receiving benefits as she had objective documentation to prove her claim.

In his first appeal, Attorney Alexander Palamara made several arguments which challenged Prudential’s denial and detailed the objective medical evidence supporting her claim, including the support of two of our client’s treating physicians, who opined our client did not have the capacity to perform any type of work on a full time basis.

Less than two months after Attorney Palamara filed his appeal on behalf of our client, Prudential agreed with Attorney Palamara and her long term disability benefits were reinstated and all back benefits that were owed to our client were paid in full.

Unfortunately, two years later in 2016, Prudential once again made the decision to deny our client her long term disability benefits. This time, Prudential stated that it had “determined that the medical information received did not support impairment that would prevent [her] from performing material and substantial duties of any gainful occupation.”

As is common in most group Long Term Disability Policies, what it means to be disabled changed after 24 months of benefits were received. In this case, in order to continue to receive benefits, instead of proving that she was unable to perform the duties of her own occupation, now our client had to prove that she was unable to perform the material duties of any gainful occupation. A review of Prudential’s denial letter and claim file revealed that Prudential’s decision was based on the opinion of an in-house clinical reviewer who found the opinions of two of our client’s treating physicians questionable because their restrictions appear “overly restrictive” given our client’s own claim reported abilities.

Attorney Palamara once again challenged Prudential’s decision, highlighting supportive objective medical evidence that was overlooked by Prudential in its review and emphasizing the highly questionable tactic of an insurance company finding fault in a claimant who reports a higher level of physical capabilities than her own doctors believe she is capable of.

Claim Approval

Thankfully, our client’s claim was once again reapproved and all back benefits that were owed were paid in full. With the assistance and support of her treating providers and their medical records, Attorney Alexander Palamara was able to successfully argue to Prudential that our client is unable to perform the material and substantial duties of her own occupation and unable to perform the duties of any gainful occupation.

Our client is relieved to be back on claim on claim and was happy to receive the benefits that should have been paid. Based on Prudential’s conduct, our client knows that the fight will never end, but she also knows that Attorney Alexander Palamara will do whatever it takes to keep her on claim until she is able to return to work or until her policy expires.

If you have been denied disability benefits by Prudential or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer for a free consultation.