Prudential Denies Long Term Disability Claim Due to Insurance Fraud

Our office was recently contacted by an insured whose claim for long term disability benefits had been recently and abruptly denied by Prudential based on allegations of insurance fraud stemming from answers provided in an Activities of Daily Living Questionnaire (ADLQ) form and a subsequent field interview. For anyone on claim with Prudential, or with any disability insurance company for that matter, the ADLQ form is a very common claim form focused on the physical daily abilities of an insured. What are often overlooked on the form are the fraud warnings that precede the signature line.

As we have indicated throughout our website, it is imperative to answer the questions contained on any claim form honestly as quite often an insurance company will use the answers provided on a claim form to undermine the honesty and credibility of an insured. This is especially true of medical conditions that have a large element of subjective symptoms and complaints- such as pain and fatigue. Over embellishment of symptoms or underreporting of activity can result in a denial of benefits, especially when video surveillance is performed.

Prudential argued in the denial letter that the insured’s responses on the form were purposefully misleading and meant to deceive Prudential. On the ADLQ in issue, the insured indicated he could not drive, go shopping for himself, perform physical activity, and that he had to use a walker or wheelchair at all times. Based on the answers on the ADLQ Prudential became suspicious of the insured’s level of impairment and placed him under video surveillance. During the course of the surveillance Prudential captured the insured going to the gym, driving, walking without the use of a walker or wheelchair with apparently no issue, and grocery shopping.

Prudential followed up the video surveillance with an in-person meeting with one if its field interviewers. During the course of the interview Prudential states that the insured indicated that he was not a member of any gym; would only drive a couple times a year if necessary to attend a medical appointment; and that he did not drive to the grocery store due to his restrictions and his need for someone to push his wheelchair. These answers were in direct conflict with the video surveillance. Prudential’s field interviewer then advised the insured of the contents of the video surveillance, at which time Prudential alleges that the insured admitted to lying on the ADLQ as he “did not want to lose his benefits.”

A short time later he received a denial letter in which Prudential asserted that he knowingly committed insurance fraud under Florida law and that his claim was being terminated. There is no indication at this time that Prudential reported the insured to the state of Florida for criminal charges, but that is not to say that the issue was not reported or will be reported.

The importance of accurately completing disability claim forms

Typically, the activities that were observed during the course of the surveillance would not have amounted to any level of fraud. However, the answers on the ADLQ and the answers given during the course of the field interview is what took something benign and raised it to a level of potential criminal action.

It is worth noting again that many claims for disability benefits are based largely on credibility as a large number of disabling medical conditions have symptoms that are deemed subjective. If you give an insurance company a reason to question your credibility, as was the case above, they will not give credibility to your medical complaints.

Comments (2)

  • Kevin, under the policy you would have the duty to pursue sources of Other Income. In this case that would be SSDI. Failure to apply for SSDI (especially when requested by the carrier) can result in Prudential offsetting your benefit by the estimated SSDI amount. If you apply for the benefit and sign any form that indicates you will repay any applicable overpayment if you are awarded SSDI they may lift that offset.

    Stephen Jessup Jul 2, 2022  #2

  • Allsup with Prudential make the change without my approval. LTD was till 2025 now they do this; “Failure to return the signed Reimbursement Agreement and proof of application for Social Security Disability Benefits by the above date, will result in the application of an estimated SSDB offset of $1,859 a month. This offset will be directly subtracted from your LTD benefit effective June 1, 2022 thereby reducing the amount of LTD benefits you are currently receiving” cut 50% with the so called warning for me to sign SSDB why would i sign 50% cut? I’m agreeing to your consultation.

    Kevin Jul 1, 2022  #1

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We represent Prudential clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Prudential disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Prudential. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Prudential.

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Our lawyers help individuals that have either purchased a Prudential long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Prudential:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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David B.

I was faced with a very difficult situation. Being disabled was bad enough but being accused of faking my condition just added to all the stress, not to mention the obvious financial shortfalls of not being able to work. Soon my claim was cut off. My insurance company had me right where they wanted me.

I have come to learn that the laws that apply to large insurance companies have been lobbied by them. The deck is stacked against the claimant. I also learned that when you make an appeal to your insurance company that is your whole case. If you go to trial, ERISA laws are in place to make your appeal your whole argument and it can’t be added to after the fact. Your initial appeal is vital if you are to succeed.

Your appeal is key. There is no doubt in my mind that had I tried to take my insurance company on by myself they would have prevailed without having to pay anything. I would have fallen into the trap that is set by them.

Dell & Schaefer’s very capable attorney Rachel Alters put a strong case together and knew all the potential pitfalls. Rachel was very patient with me and worked methodically to compile an 800 page appeal. We were able to beat them at their own game. I was able to receive a significant settlement because the case had been made on the terms that the law requires.

I can not stress enough the need for strong representation when and individual goes up against these huge companies with unlimited funds to fight paying what they should.

***** 5 stars based on 202 reviews

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