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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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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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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Jim F.

My employer offered both Short Term Disability and Long Term Disability insurance as optional benefits among others. The premiums were significant, but since they could be payroll deducted I felt they could be reasonably managed and the security of continued income in the event of a medical disability was well worth the investment. As with the purchase of a first aid kit, most would prefer never having to use it.

I have been very fortunate to have had few illnesses or injuries throughout my life and more specifically my 45 year career as a healthcare professional. It wasn’t until early in 2012 that I was diagnosed with a chronic, progressive disease of the eye. Symptoms were minimal at that time, though regular visits to a retinal specialist, including regular therapy by ocular injection, were necessary to slow its progression, the symptoms did not appreciably interfere with my work. In spite of my treatments the condition continued to progress. In early 2014 the symptoms began to interfere dramatically with my day to day duties. My job required significant computer use and the reading of copious amounts of medical documentation. It became evident to me that I could no longer meet the expectation of my management and clinical position without working frighteningly long hours and enduring the relentless eye strain and other symptoms related to the illness.

Though I had always planned for eventual retirement from my full-time position, like most professionals I had hoped to be able to continue to practice my profession on a part-time basis throughout my retirement as long as I remained competent and able. That was not to be. Thankfully, I had the foresight to elect the disability benefit options offered by my company and have the premiums payroll deducted for many years. I notified my supervisor and HR representative that I had to stop working due to my condition and proceed with the disability application process.

All went very well and after using up my accrued vacation and sick time, my short-term disability benefits commenced. Since my condition is progressive and incurable I felt secure in knowing that once my short-term benefits were exhausted my benefits would continue under the long-term policy. However, much to my surprise, after receiving about a month of benefits I received notification from the insurance company that a decision had been made to terminate my benefits due to lack of objective medical evidence to support my claim, though significant documentation had been provided by my retinal specialist.

I was bewildered and unsure of how to proceed with an appeal of that decision. Since I had 180 days to do so, I decided to research the matter thoroughly. In spite of my being a veteran healthcare professional everything I had been reading on the subject cautioned about attempting to proceed with an appeal on my own. Legal representation was highly recommended.

I then began a review of local attorneys, hoping to find one that provided enough documentation on their website that indicated experience with non-social security disability related cases. I was also interested in seeing evidence of some experience with disability cases related to diseases of the eye and resultant vision impairment. I was unsuccessful.

So I expanded my search to include national law firms. It was then that I discovered Dell & Schaefer. After thoroughly reviewing their website, watching many of the video discussions, noting experience with vision related cases, particular documentation related to the insurance company that handled and then eventually denied my benefits, and reading a significant number of testimonials, I decided to request a free consultation as advertised. It was one of the best decisions I have ever made.

After that consultation, I was very confident that I was in very skilled hands which alone reduced my anxiety level immensely. Attorney Alexander Palamara and his Legal Assistant, Kathleen Bordes, immediately began managing my case, their professional expertise clearly evident.

They worked closely with my retinal specialist, my optometrist and the insurance company in compiling the medical documentation necessary for a successful appeal in an amazingly short period of time, keeping me fully informed all along the way. Shortly after being notified by the insurance company that my benefits would be reinstated and paid through the full term of my short-term policy I received a lump-sum payment.

Once the short-term disability appeal was successfully completed, Alex and Kathy immediately addressed the long-term policy benefits. Again in a remarkably short period of time I was granted those benefits, receiving a lump-sum payment for benefits to date and will receive a payment monthly going forward per the terms of my LTD policy.

I am extremely pleased with how my case was handled and the very favorable outcome. Alex and Kathy were a delight to work with and extremely professional in every way. Incidentally, the fee I paid to Dell and Schaefer for their incredible representation was very reasonable and very well earned.

I highly recommend the services of Dell & Schaefer to anyone who may find themselves in a similar disability-related situation.

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