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Prudential Denies Long Term Disability Claim Due to Insurance Fraud

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

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.



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