Prudential Approves Disability Claim on Appeal

Our client, an Emergency Room Physician, had a long history of complications due to Crohn’s disease, which stemmed all the way back to his childhood. Despite persistent, recurring bouts of distress and flare ups associated with the disease he was able to finish college, then medical school, followed by residency and ultimately finding himself in an extremely active emergency room for a major hospital system. However, the frenetic pace of working in an emergency room environment did not come without a toll on his body. As the years passed he began to experience more frequent bouts of increased symptoms related to his Crohn’s that eventually culminated in him having to file a claim for disability benefits under his employer provided group disability insurance policy with Prudential.

At the time he ceased working his condition was so severe that he soon found himself the patient undergoing surgery in an attempt to alleviate the significant abdominal pain he was experiencing, a pain that made it difficult for him to eat and drink let alone practice emergency room medicine. Prudential initially approved his claim for short and then his long term disability benefits in light of the surgery he underwent. However, not long after approving his long term disability benefits problems with Prudential began for our client. Despite being a medical doctor familiar with the taking of medical records and presumably more cautious with what his doctors were stating in his own,  our client was blindsided when he received notice from Prudential that his claim was being terminated, in part,  based on his doctor’s medical opinions regarding physical abilities.

The Appeal

Following the denial of his long term disability claim he contacted our office and spoke to Attorney Stephen Jessup. In reviewing the denial letter and subsequent claim file it was apparent that the basis for Prudential’s denial was twofold: (1) Prudential’s review focused solely on recognized standards relating to rate of recovery for surgery and (2) the cherry picking of portions of our client’s medical records to fit the dialogue Prudential needed to terminate benefits. As to the idea of a “reasonable time of recovery from surgery” Attorney Jessup attacked Prudential’s position based on the fact that despite the time that had passed since the surgery, and the fact that our client’s surgery was deemed “successful,” our client’s symptoms had not subsided to a level that would allow him to return to his former occupation as an emergency room physician; and secondly that the guidelines with which Prudential was utilizing did not take into consideration our client’s occupational duties. As such, the recognized standards for rate of recovery were meaningless in the context of client’s abilities to perform the material and substantial duties of his occupation.

Attorney Jessup then addressed issues that were perceived to exist within our client’s medical records, which deeper evaluation of same yielded valuable information that Prudential was overlooking. Despite indication from our client’s doctor that he would have certain physical abilities, which Prudential interpreted to mean he could perform at the physical demand level of his occupation as set forth by the Department of Labor, the opinions of our client’s doctor as a whole were quite clear that he believed our client would not be able to meet the multiple physical and mental demands of an emergency room physician due to his ongoing symptoms and as such could pose a potential risk to the safety of patients should he return to work prematurely. In coordination with our client’s doctor, Attorney Jessup prepared an attending physician’s statement for the doctor to complete, which refuted Prudential’s opinions and clarified our client’s work restrictions and limitations.

The Appeal Decision

After submitting the appeal it became clear that Prudential was not going to approve our client’s benefits without a fight. As the initial 45 day deadline with which to render a decision on the appeal quickly neared our office received notice from Prudential that it was scheduling an Independent Medical Examination for our client and in turn, exercising its right to a 45 day extension to review the appeal. As our client’s claim was governed by ERISA, Prudential was essentially pulling out all the stops to establish it provided our client with a full and fair review of his claim and that any subsequent denial would be deemed reasonable.

In advance of the IME, Attorney Jessup and our client communicated multiple times regarding the exam and the doctor who would be performing. Unlike many IMEs in which the examining doctor spends an appreciable amount of time performing insurance company exams, the doctor selected by Prudential was a clinician who worked for a hospital system local to our client. Believing that honesty is one’s strongest asset when it comes to a disability insurance claim that is based heavily on “subjective” complaints of pain and fatigue, Attorney Jessup was confident that our client’s medical history and character would speak for itself.

Ultimately, the truth prevailed. Based on the information presented and argued in the appeal and the results of the IME exam, Attorney Jessup received notice from Prudential that it was overturning the denial of our client’s claim and forwarding almost a year’s worth of past due benefits.

What This Means For Your Disability Claim

Our client is on the road to recovery and has every intention of returning to work in the not too distant future. However, for countless insureds that is not the case and the monthly disability benefits they receive from their insurance carriers represent their financial stability and well being. This case serves as a reminder that it is crucial that one’s medical records accurately reflect information that supports one’s disability, as well as the importance of ensuring the claim forms submitted by a treating physician accurately reflect an insured’s problems.

If your claim for disability is predicated on a surgical procedure we would caution you that all insurance companies will evaluate your claim under the pretext of a “reasonable time of recovery” from the procedure. You may have already even been questioned by your insurance carrier as to same, and if so it becomes all the more important that your medical complaints, symptoms, restrictions and limitations are being properly documented by your doctor.

If you have any questions regarding your disability insurance claim please do not hesitate to contact our office to speak with one of our disability insurance attorneys.

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