Prudential denies long-term disability benefits to a college professor, but the California District Court reverses the claim denial
The recently decided case of Barteau v. Prudential, 2009 WL 1505193 (C.D. Cal.) is a reminder of what ends Prudential will go to in denying a claim for benefits. Carl Barteau was an Assistant Professor of Mathematics at DeVry Institute of technology for almost eight years before becoming disabled. Mr. Barteau had suffered problems with his right eye since childhood. In 2002 he underwent surgery for glaucoma, which was complicated by a scratched cornea. As a result of the scratched cornea he was instructed to wear a replaceable contact lens and was reassured the eye would heal on its own. Soon after he began experiencing excruciating pain, and on January 7, 2003 he began treatment at UCLA. Biopsies of the eye were taken and showed evidence of eye fungus. On January 17, 2003, he became hospitalized and underwent surgery to remove a large part of the infection from his right eye. On February 22, 2003, he underwent a second surgery on his right eye. Following the second surgery he began to experience a lack of vision in his right eye and disabling light sensitivity in both eyes.
Mr. Barteau filed for short term disability under his employer’s Group Plan, effective January 7, 2003, and was awarded short term disability benefits for the maximum period. As the period of short term disability benefits began to wind down, he attempted to return to work, but his conditions were such that he was unable. On July 2, 2003, he filed for and received long term disability benefits due to loss of vision in his right eye, eye strain to his left eye, headaches and blurry vision.
After Prudential approved his long term disability benefits, Prudential advised Mr. Barteau of his duty under the group plan to apply for Social Security benefits. Mr. Barteau applied, and was denied in December of 2003. Prudential then offered the services of a company to help him appeal the decision.
While the social security appeal was ongoing, Prudential began to investigate Mr. Barteau’s claim in March of 2004 to determine whether or not he was still disabled. Prudential determined in August of 2004 that his condition had remained the same based upon the notes and medical records from Mr. Barteau’s treating physicians. However, this did not stop Prudential from investigating his claim again in September of 2004. Despite evidence of impairment in his medical records Prudential determined that his eye condition should not preclude him from working and requested additional medical records from his eye doctor, which clearly indicated that his eye condition was leading to severe eye strain and migraine headaches. Prudential, realizing they did not have an avenue to deny benefits based on those records then requested medical records from Mr. Barteau’s primary care physician. After receiving and reviewing these records along with those of Mr. Barteau’s eye doctor, Prudential determined in November of 2004 he was still disabled under the policy.
Nearing the two year mark of receiving long term disability, Prudential wrote Mr. Barteau at the end of December 2004 to inform him that in July of 2005, the definition of total disability would no longer relate to his occupation, but would change to “any occupation.” Prudential then requested in January of 2005 that a functional capacity evaluation be performed. The results of the evaluation indicated that Mr. Barteau suffered from severe headaches which precluded the attention and concentration required for even simple unskilled work tasks, and that due to the disabling cognitive impact caused by his migraines, he suffered from disabling fatigue. Shortly thereafter, on March 15, 2005, Prudential was informed Mr. Barteau’s claim for social security benefits had been approved.
It would seem reasonable to assume that since Mr. Barteau had met the Social Security definition of disability, that Prudential would consider this evidence of disability from any occupation. But this was not the case. In May of 2005, Prudential hired a vocational rehabilitation specialist to review the claim. The specialist determined that Mr. Barteau had medical complications that would impact his ability to work. Having no way to deny benefits at this point, Prudential informed Mr. Barteau in June 2005 that their evaluation had been completed and they found he was totally disabled from performing any occupation.
All seemed to be in order for Mr. Barteau, that is until March 2006 when Prudential conducted another review of his claim. Prudential requested limited medical records from Mr. Barteau’s treating physician, which created a gap of medical records of almost a year and a half! Additionally, Prudential had Mr. Barteau complete a generic form titled, “Activities of Daily Living Questionnaire.” Based upon limited medical records and a generic questionnaire, Prudential determined Mr. Barteau was not disabled from any job, and terminated his benefits without any evidence of improvement or progress in his condition and informed him on September 8, 2006 that his claim was being terminated.
Mr. Barteau informed Prudential he was also seeing an orthopedic specialist for spine pain and a bio-feedback psychiatrist. Prudential asked for proof of disability from these doctors within 30 days or the claim would be terminated. Mr. Barteau underwent MRIs and a neuropsychological evaluation in order to support his claim. However, the results of the evaluations would not be completed in the time frame required by Prudential. Upon learning this, Prudential informed Mr. Barteau that they would allow him the necessary time to obtain this pertinent information prior to any decision.
Prudential then went against its word and six days after informing Mr. Barteau they would await the results of the MRIs and neuropsychological evaluation they began their evaluation. Without receiving the pertinent information they knew was coming, Prudential terminated his benefits as of October 25, 2006.
Results from the neuropsychological evaluation were received by Prudential on November 4, 2006. The results indicated Mr. Barteau was suffering from multiple severe cognitive problems due to his conditions. Faced with objective findings of disability it would be reasonable to expect Prudential to reinstate Mr. Barteau’s benefit, but instead Prudential hired a doctor who advertised on his website that he had done over 1500 Psychiatric Disability reviews for disability insurance companies to review the neuropsychological evaluation. It was no surprise that this doctor determined that Mr. Barteau was not totally disabled from any occupation.
In filing his first appeal, Mr. Barteau also included the findings of his MRIs and electrodiagnostic studies. The MRIs indicated multilevel disc herniations in his neck and back and the electrodiagnositc testing showed evidence of acute cervical radiculopathy and chronic right lumbar radiculopathy. However, Prudential again looked for any outlet to deny disability benefits and sent only a portion of Mr. Barteau’s medical records to a hired physician and a separate medical review agency for review. Both the hired physician and medical review agency determined Mr. Barteau was not totally disabled from any occupation, and based upon this information Prudential upheld its denial.
Mr. Barteau filed a second appeal and presented additional significant and reliable evidence of disability. In the information provided office notes from 45 office visits to treat for his disabling pain, headaches, and cognitive conditions. Treatment indicated lumbar epidurals and facet blocks under fluoroscopy, along with continued cognitive dysfunctions. Prudential took the information in this second appeal and sent the information to be reviewed by the very doctors who had previously opined Mr. Barteau was not disabled from any occupation. Prudential once again upheld its denial of benefits.
Mr. Barteau then filed suit in federal court. Prudential’s underhanded and inappropriate actions in the handling of the claim were set out before the Court. In May of 2009, almost three years after being denied benefits, the Court determined that Mr. Barteau continued to be disabled under the terms of the plan when Prudential terminated his benefits. The Court asserted Prudential had done nothing to show improvement in Mr. Barteau’s condition to justify termination of benefits, nor did they present any vocational evidence which identified employment opportunities for Mr. Barteau. In making its ruling, the Court ordered all back benefits owed to Mr. Barteau be paid, along with interest. Additionally, the Court acknowledged Mr. Barteau’s right to recover reasonable attorneys’ fees, which were to be determined at a later hearing.
What appeared to be a “cut and dry” claim for disability proved to be anything but. Mr. Barteau endured numerous injustices by Prudential over the course of the three years it took to litigate his case. Mr. Barteau’s case serves as a reminder of the ends Prudential will go to in order to deny claims. In denying disability benefits, Prudential once again assumed that they could hide behind the wall of ERISA and wrongfully deny long-term disability benefits. Fortunately the court disagreed and made the right decision. It is likely that Prudential will appeal the courts decision.