Prudential Fails to Pay Long Term Disability Benefits of Claimant Suffering from Addison’s Disease

What is Addison’s Disease?

Our client is a 43-year-old male who was employed as a Manager for Microsoft for many years. He was forced to discontinue working in his highly rewarding career after being hospitalized for progressively worsening symptoms of fatigue, nausea, dizziness, diffuse pain and weight loss (20-30 pounds) which was later deemed attributable to a diagnosis of Addison’s disease. Addison’s disease, also called adrenal insufficiency, is a rare but serious adrenal gland disorder in which the body is unable to produce enough of two critical hormones, cortisol and aldosterone.

Cortisol helps the body respond to stress, including the stress of illness, injury or surgery. It also helps maintain blood pressure, heart function, the immune system and blood glucose (sugar) levels. Aldosterone affects the balance of sodium and potassium in the blood. This in turn controls the amount of fluid the kidneys remove as urine, which affects blood volume and blood pressure. Addison’s disease is caused by an autoimmune response which occurs when the body’s immune system assaults its own organs and tissues. With Addison’s disease, the immune system attacks the outer portion of the adrenal glands, where cortisol and aldosterone are made and results in chronic illnesses and symptomatology to include but not limited to:

• Extreme fatigue
• Weight loss
• Hyperpigmentation
• Low blood pressure, even fainting
• Low blood sugar (hypoglycemia)
• Nausea, diarrhea or vomiting
• Abdominal pain
• Muscle or joint pains
• Irritability
• Depression or other behavioral symptoms

After multiple ER visits for varied illnesses, our client was ultimately hospitalized for persistent and severe symptoms of dyspnea, generalized weakness, headaches, vertigo, nausea and vomiting with episodes of hypoglycemia as well as significant weight loss at which time he was diagnosed with primary adrenocortical insufficiency (Addison’s disease) based on his low cortisol level on stim test and high ACTH as well as acute kidney failure; and other specified hypothyroidism.

If I go back to work after a period of disability and then go out again for the same disabling condition can I still collect disability benefits?

Our client applied for disability insurance benefits under his policy with Prudential as his condition was of such severity it precluded his ability to perform, with reasonable continuity, the duties of his occupation.  Prudential initially approved his claim for short term disability, paying benefits through his attempted return to work date. Unfortunately, his return to work was not successful as he suffered a relapse of severe symptomatology forcing him to go back out of work. Prudential unreasonably refused to pay benefits as of his relapse date, and in a letter denied his claim for further STD benefits, falsely asserting that his medical information “did not demonstrate a global functional deficit”. This was alarming as the medical records documented the same (if not worsened) symptomatology that Prudential initially found to be disabling. Due to the severity of his symptoms, he was forced to relocate for much needed family support as he battled his illness. His employer even afforded him additional accommodations such as work from home option to assist him as he struggled with his medical condition.

Three days after he ceased working again, he was seen for treatment by his primary care physician. At that time, it was noted that he was experiencing increasing weakness, especially in leg muscles, lack of energy, loose stools, and fasciculation in his eye. It was recommended that he undergo a neurology evaluation for possible multiple sclerosis. He was subsequently seen in consultation with neurologist who confirmed the multitude of systemic issues to include extreme fatigue, muscle cramps, and weakness, along with difficulty with concentration, confusion, and slurred speech. While he noted that the neurological examination was unremarkable, he confirmed that he has “seen cases of a demyelinating process even with as little physical expression as his patient currently has”. Therefore, he recommended further diagnostic evaluation to include brain imaging.

It could not have been more evident based on our clients extensive medical records that he in fact had (and continues to have) a severe functional impairment stemming from his diagnosis of Addison’s disease that precluded his ability for sustained work activity. Prudential’s decision to deny his claim for STD benefits as of his relapse date was not only wrong but arbitrary and capricious. Clearly frustrated and perplexed by Prudential’s contradictory determination, he retained attorney Rachel Alters to appeal the adverse benefit determination on his short-term disability claim.

Extremely ill and with the added stress of no income, he pushed himself to return to work but again this was not without several accommodations by his employer. He remained under treatment with his doctors whose treatment notes substantiated his ongoing symptoms to include but not limited to fatigue, arthralgias, and myalgias. In addition, he continued to undergo medication adjustments to determine the optimal steroid level to manage his symptomatology. Of note, in its initial approval of STD benefits, Prudential itself confirmed that it was reasonable to allow time after medication adjustment to ensure optimal therapy. Therefore, going by Prudential’s own guidelines, he would have had to take time off  from work each time his medication was adjusted. This does not allow for sustained work activity and would certainly exceed the normally accepted standards for absenteeism in the workplace.

Unfortunately after struggling to work for approximately two months, he was once again forced to cease working at which time he also applied for Long Term Disability (LTD) insurance benefits. He was admitted to the hospital and  diagnosed with unspecified adrenocortical insufficiency, other fatigue, myalgia, and pain in unspecified joint. His severe and ongoing disability was subsequently confirmed in multiple physician statement forms which were completed by different physician specialists all in agreement that due to Addison’s disease and its accompanying symptomatology he was no longer able to perform the duties of his occupation at Microsoft. The severity of our client’s condition and the impact it had on his ability to engage in sustained work activity was recognized by all who came in contact with him EXCEPT Prudential who once again, in spite of the overwhelming medical evidence, attempted to deny his claim for STD benefits. Fortunately, being fiduciary on its STD plan and having not only firsthand knowledge but also direct observations of the debilitating effects of his condition, with the help of his attorney as well as his employer who intervened and persuaded Prudential to approve his STD claim.

If My Short Term Disability Claim is Approved, Does That Also Mean My Long Term Claim Will Be Approved?

In accordance with our client’s employer’s request along with the appeal filed by our law firm, Prudential reinstated his STD claim and paid benefits to the end of the STD maximum benefit period. However, Prudential proceeded to unjustly deny his claim for LTD benefits falsely asserting that there was no support for impairment. Prudential’s determination was incomprehensible. Not only was its decision wrong, but also irresponsible, unethical, and unjustifiable. Prudential relied on the biased opinion of its own physician consultant who unlike our client’s multiple treating physicians did not have the benefit of examining or even observing him. Despite the request from our client’s employer to perform an Independent Medical Examination, Prudential failed to do so, even though such examinations are actually provisioned for in its policy. It was evident that Prudential was aware that the results of such examination would not facilitate its pre-determined plan to deny LTD benefits as they would clearly substantiate his obvious and severe disability.

Ultimately, Prudential’s conclusions and its decision were not just wrong, flawed and erroneous, but also arbitrary and capricious and demonstrative of an abuse of any purported discretion they may have under the LTD Policy. Our client continued to have a severe functional impairment stemming from his condition that prevented him from performing with reasonable continuity the material and substantial duties of his occupation. He remains under regular treatment with his endocrinologist, and his current treatment notes continue to substantiate his ongoing issues with debilitating fatigue as well as an array of complex symptomatology stemming from his diagnosis of adrenal insufficiency which is consistently documented as poorly controlled.

In June of 2020, our client was seen in emergency room on three occasions in one week, due to flares of symptomatology to include acute dehydration, cramp, spasm, disorientation, intractable headaches, weakness, neck stiffness, nausea, diarrhea, upper abdominal pain, and extreme fatigue. During the June 10, 2020 ER visit, his Addison disease was documented as “currently markedly symptomatic”. On June 29, 2020, he was seen by his neurologist who confirmed his “Addison disease decline”, with no consistent improvement despite chronic daily steroid treatment and multiple adjustments to include a recent change to dexamethasone in January of 2020. Prudential still refused to pay his LTD claim.

If I’m Approved for Social Security Benefits Does Prudential Have to Approve My Benefits?

On August 4, 2020,  our client was approved for disability benefits under the Social Security Administration’s (SSA) disability benefit program. Utilizing, much stricter guidelines than those of Prudential’s LTD policy, SSA agreed that his condition rendered him totally disabled and unable to engage in any form of substantial gainful activity. As a qualification for disability benefits under SSA program, one’s medical records much substantiate the presence of a severe impairment that will last for at least 12 months or result in death. Therefore, SSA’s determination substantiated his disability under Prudential’s LTD policy and supported his inability to engage in sustained work activities in his own occupation or any gainful occupation.

However, Prudential ignored the favorable determination by the SSA and still refused to pay our client’s LTD benefits even though it could not be clearer, based on the aforementioned, that he was disabled according to the terms of the LTD policy. Even after all this evidence was presented, Prudential continued to refuse to pay our client’s long term disability benefits. Rachel Alters filed suit against Prudential in Federal Court demanding that her client’s LTD benefits that he was rightfully owed be paid. Ultimately the case was resolved in a confidential settlement.