Prudential Approves LTD Claim on Voluntary Appeal
Author: Attorney Stephen Jessup
Prior to hiring our office, our client, a former director for a large university tasked with ensuring securing donations and fundraising, filed for disability insurance benefits with Prudential following surgery for a right hip replacement. Prudential initially approved our client’s claim in light of the surgery, but was soon making inquiries as to her continued restrictions and limitations as her initial recovery period for the surgery was coming to an end. Although she had every intention of returning to work following the prescribed recovery time, the surgery, which was successful in that the hip replacement occurred- was not successful in alleviating her pain. Our client explained to Prudential that she continued to experience debilitating pain in her hip, which affected her already well established lumbar degenerative disc disease, making it difficult for her to perform daily activities, let alone the rigorous requirements of her occupation. Despite her ongoing physical restrictions, our client’s claim would come to an abrupt end after her surgeon advised Prudential that he had cleared her for return to work and was not supporting any restrictions and limitations. In light of these opinions, Prudential terminated her claim for benefits.
The First Appeal
At that time our client filed her own first appeal of Prudential’s denial. Not understanding the importance of an administrative appeal of a group disability insurance denial she only proffered a two page letter refuting her doctor’s opinion and reiterating the complaints and restrictions she advised Prudential of prior to her denial. She did not provide any additional medical information or opinion that supported her complaints, nor did she provide any rebuttal opinion and/or clarification as to the comments previously made by her doctor.
During the course of the appeal review Prudential had her claim reviewed by a doctor board certified in Physical Medicine and Rehabilitation with Pain Management. After reviewing the opinions of our client’s doctors, the peer review physician determined that she would have the ability to work at what would constitute a “light” duty occupation as set forth by the Department of Labor. Furthermore, the peer review physician indicated that these restrictions would be applicable for only six months at which time they would need to be revisited as the doctor anticipated continued recovery. Prudential then sent the peer review physician’s report to their vocational department for analysis as it related to our client’s occupation. Based on the peer review physician’s opinion, Prudential’s vocational department further determined she would be able to perform the material duties of her occupation. Prudential advised our client it was upholding the denial of her claim.
The Voluntary Second Appeal
Following the denial of her first appeal our client contacted our office and spoke with Attorney Jessup to discuss her seemingly endless fight with Prudential. In reviewing the information in our client’s file it was clear to Attorney Jessup that the biggest obstacle to overcome would be refuting the opinion of our client’s own surgeon, followed by presenting new information to support her disability that would also be applicable to the timeframe in which her claim was first denied.
A sliver of hope soon appeared following Attorney Jessup’s review of our client’s formal claim file from Prudential; namely, the lack of medical records from certain treating providers that helped to paint a better picture of our client’s overall level of impairment and functioning. Although our client had assumed that Prudential had collected records from all of her doctor’s she had made them aware of, Attorney Jessup knew that more often than not an insurance company will not seek out all medical records, and place the onus on the insured to provide applicable medical documentation. The sliver of hope soon became a doorway with which to establish our client’s disability in the form of diagnostic test results and imaging studies, medical statements, and targeted questionnaires from our client’s doctors as they related to her ability to work. Attorney Jessup further argued that Prudential’s reliance on our client’s surgeon’s opinion was unfounded as the surgeon had not seen our client for several months following the surgery and as such was not the proper physician to have consulted with during the course of Prudential’s review for continued benefits.
Despite having a viable argument to support our client’s disability, Attorney Jessup was cautiously optimistic in submitting our client’s appeal due to the fact that during a voluntary appeal Prudential would not be required to send our client’s file to a new doctor for review and could send the information back to the peer review physician responsible for denying her first appeal for further review. Convincing a doctor that their previously provided opinion is wrong is never an easy task. Prudential increased the difficulty further when they notified Attorney Jessup that they had arranged for our client to undergo an Independent Medical Examination (IME).
In advance of the IME, Attorney Jessup and our client communicated thoroughly as to what to expect and how to present during the exam. Attorney Jessup, believing in the truth of our client’s disability claim, felt that the IME would provide our client with the opportunity to have her complaints and character fully examined, as opposed to leaving her claim in the hands of a doctor who only examined a stack of papers. Despite the inherent risk when an insurance company requires an IME, our client was vindicated when Attorney Jessup was advised shortly after the IME that our client’s claim was approved.
Attorney Jessup continues to represent our client in her continued claim with Prudential. Despite the fact she only has a limited time left on her claim Prudential has already begun its requests for updated medical information and claim forms. As our client has learned, there is no such thing as a guaranteed disability benefit, and one must remain vigilant to ensure benefits are continue to be paid.
If your claim for disability insurance benefits has been denied, or you have questions pertaining to your disability claim, please do not hesitate to contact our office to speak to one of our disability insurance attorneys.