Prudential reverses decision to terminate LTD benefits of MRI Tech with Primary Progressive Multiple Sclerosis and degenerative Disc Disease

The claimant is a 58-year-old former MRI Technologist for Fairview Health Services who has long suffered from the debilitating effects of her chronic medical conditions. She has a history of neck pain as well as right arm pain and numbness dating back to 2005 with a reoccurrence of severe symptomatology in 2013. MRI of her cervical spine performed in August of 2013 revealed the presence of multilevel degenerative changes and MRI of her brain also performed demonstrated an abnormal focus of T2 signal above the level of the stenosis which prompted further evaluation for demyelinating disease. The claimant was diagnosed with multiple sclerosis, based on the findings of white matter lesions in the spinal cord and periventricular regions, accumulation of additional lesions on brain MRI after onset of symptoms. Subsequently, on March 12, 2014 and May 22, 2014, respectively, Ms. Kleindl underwent C6-C7 anterior cervical discectomy and posterior cervical foraminotomy due to increased radicular neck and arm pain attributed to diagnosis of cervical radiculopathy complicated due to MS flare. As a result of her conditions and the restrictions and limitations associated with them, she was forced to cease working in May of 2014 and apply for disability insurance benefits under the Fairview Health Services Long Term Disability Policy administered and funded by Prudential.

Prudential terminates benefits on multiple occasions even though Claimant’s condition continued to deteriorate

Prudential found the claimant to be totally disabled — i.e., unable to perform the material and substantial duties of her regular occupation – and by letter dated May 30, 2014 approved her claim for long term disability benefits. Alarmingly, after paying benefits for approximately 18 months, Prudential, despite the evidence of progressively worsening neurological/cognitive symptomatology and ongoing severe chronic pain, unjustly terminated the LTD claim effective November 12, 2015, falsely asserting that she no longer had any restrictions and limitations stemming from her severe diagnoses. Not only was their opinion unfounded but illogical considering her medical history and the extent of medical evidence to include objective diagnostic examination substantiating her total disability.

After an extensive appeal process, Prudential was ultimately forced to acknowledge the ongoing demonstrated severity of the claimant’s impairments which rendered her totally and permanently disabled, and by letter dated November 10, 2016, reinstated her benefits retroactive to the November 12, 2015 termination effective date. In a medical opinion report dated November 4, 2016, Prudential’s own contracted physician consultant, Dr. Behzad Emad, rejected Prudential’s prior assertion that she had no restriction and limitation as of November 12, 2015.

There has been no demonstrable improvement in the claimant’s condition since Prudential’s November 2016 decision to reinstate benefits, and given the nature of her diagnosis, Primary Progressive Multiple Sclerosis (PPMS), none is expected. PPMS is one of the more severe types of multiple sclerosis and it inevitably results in disability. Even with treatment, PPMS leads to a progressive loss of neurological function. This is evident in her ongoing medical evaluations and treatment and affirmed in Prudential’s own subsequent medical reviews. Prudential’s physician consultants have consistently opined an ongoing severity of impairments with worsening which substantiates the need for medically supported restrictions and limitations that would prevent her from engaging in sustained gainful work activity as stipulated in the LTD policy. Yet Prudential terminated her benefits yet again claiming she was well enough to return to full time work.

Unqualified Peer Review Physician

Given the aforementioned opinions from Prudential’s own medical and vocational consultants, as well as the extensive medical evidence substantiating the claimant’s permanent and total disability to include a favorable determination from the Social Security Administration, it is unconscionable that Prudential by its letter dated April 29, 2022 would terminate her LTD benefits effective May 1, 2022, asserting that she was no longer disabled. There was no proper ground or defensible basis upon which to terminate LTD benefits as the medical evidence – including the diagnoses, assessments and findings of the claimant’s attending physicians and Prudential’s physician consultants, based on examinations, tests, scans, review of medical records and extensive statements of her treating physicians and neuropsychological testing – substantiated an ongoing severity of impairments that would not allow for any reasonable or reliable return to full-time sustain work activities especially in the high level occupations identified. Relying on the opinion of one of its own biased physician consultant, Dr. Ge Ma, Prudential wrongly concluded that the claimant, after 8 years of disability due to a progressive disease, now had the capacity to work 8 hours a day and 40 hours a week in a sedentary capacity.

It is evident that Prudential arbitrarily selected its medical consultant, Dr. Ma, knowing that this occupational medicine physician was not the most appropriate to opine on the claimant’s complex neurological conditions but he would likely facilitate goal to terminate benefits based on his lack of knowledge regarding her complex neurological diagnoses and symptomatology as well as his eagerness to appease “employer” (Prudential). While Prudential had the option of pursuing an updated opinion from their neurology specialist Dr. Leonard Topper who would have been the most appropriate to opine on her progressive condition and prognosis for recovery, they chose not to do so as they were aware that his opinion would likely substantiate the claimant’s ongoing disability. Furthermore, although such examinations are provisioned for in the policy, Prudential did not pursue a neurological IME or functional capacity evaluation or even as much as request a neuropsychological evaluation given the irrefutable evidence of cognitive dysfunction characteristic of MS in her claim. It is clear that Prudential’s focus was not on affording the claimant a full and fair review but rather on avoiding further financial liability under the LTD policy.

A Functional Capacity Evaluation Confirms Claimant Cannot Perform Sedentary Work

Upon recommendation from her treating doctor, the claimant commenced physical therapy on September 6, 2022. Her weekly treatment notes confirms her struggle with SI joint and leg pain; gait dysfunction, and debilitating fatigue. It was noted that she was utilizing a cane to assist with ambulation and balance. Her primary functional limitation was reflected as her inability to ambulate in or out of home without falling; and her secondary functional limitation was her inability to sit or stand for prolonged periods without back pain. On October 25, 2022, she underwent a functional capacity evaluation (FCE) which took place over two days. The results of the FCE, which was deemed a valid and reliable estimate of her residual physical capacity, confirmed she did not have the sustained physical ability to perform sedentary work.

After reviewing the appeal submitted by Attorney Rachel Alters, Prudential overturned the erroneous determination, paid all the back benefits owed to the claimant and she is currently received monthly disability payments. Attorney Alters is currently managing this claim to help ensure Prudential continues to pay these benefits.