Research Epidemiologist with chronic fatigue / ME wins LTD appeal against Prudential
Our client is a former Mental Health Epidemiologist who unfortunately suffered the progressive onset of pervasive fatigue, malaise, muscle aches, headaches, difficulty with concentration/focus, difficulty with information processing, and depression. Her symptoms were attributed to the medical diagnoses of chronic fatigue syndrome / Myalgic encephalomyelitis by her treating physicians to include her psychologist. Our client’s symptomatology were of such severity they interfered with her ability to reasonably and reliably perform her high-level occupational duties which included PhD level research and analysis. She was ultimately forced to significantly reduce her work hours in June of 2017, but when her condition failed to improve (but rather worsened), she had to cease working completely in October of 2019.
She applied for disability insurance benefits under her policy with Prudential, appropriately asserting a date of disability back to 2017 when she was first forced to reduce her work hours. After an extensive review of her medical records, Prudential agreed that the severity of her condition would have in fact precluded her ability to perform the material and substantial duties of her regular occupation on a fulltime basis. Therefore, by letters dated November 6, 2020 and November 10, 2020, Prudential approved her claims for both short- and long-term disability benefits retroactive to her date of disability of July 1, 2017. Unfortunately, recognizing the high value of her claim, Prudential sought to limit its liability under the LTD policy and in doing so, wrongly applied the policy’s 24-month limitation for disabilities due to a mental/nervous condition. By the same approval letter dated November 10, 2020, Prudential unjustifiably terminated her LTD benefits effective December 30, 2019 based on the policy’s limitation.
Prudential’s decision to terminate benefits was not only wrong but arbitrary and capricious and demonstrative of an abuse of any purported discretion it may have under the LTD policy. It could not have been clearer from the medical evidence that our client’s disability stemmed from her medical diagnosis of chronic fatigue syndrome/myalgic encephalomyelitis and her acute symptoms of depression was a sequela of her medical condition. Medical records from Duke Health dating back to February of 2017 confirmed her ongoing struggle with exhaustion and related difficulty concentrating. On February 2, 2017, it was documented “need to rule out other possible causes because not really sure it is depression”. After extensive testing, chronic fatigue syndrome was ultimately determined to be the etiology of her severe symptomatology. In February of 2018, Dr. Juliet Cheng Brown, psychologist, also confirmed that despite our client’s mood symptoms being under control she continued to have significant issues with severe fatigue. Dr. Brown’s ongoing treatment notes further indicated that she was not exhibiting typical depressive type symptoms. In a letter dated April 14, 2020, Dr. Brown documented that her chronic fatigue significantly limited her work performance and this in turn adversely impacted her mood.
In a subsequent correspondence written in response to Prudential’s biased physician consultant review, Dr. Brown confirmed and clarified that our client has been under her care since 2016 and that:
- Her symptoms were not presenting like typical depression and occurred abruptly after an upper respiratory infection which is common for ME/CFS not depression.
- Her mood symptoms and related cognitive dysfunction stemmed from ME/CFS not the other way around.
- Her mood symptoms are the least impairing of her symptomatology, and
- Her response to behavioral health treatment has not been “typical, sustained, and has not resolved the majority of her symptoms”. Specifically, her treatment was not able to ameliorate her most impairing symptoms of fatigue.
Although Dr. Brown’s letter along with the medical records clearly demonstrated chronic fatigue as our client’s primary disabling condition, Prudential irresponsibly dismissed this information solely on the basis that Dr. Brown is a psychologist and not a medical professional. However, as a psychologist who has been treating her for several years, Dr. Brown was in fact the most appropriate to confirm if her disability stemmed from a behavioral health condition. Therefore, while she may not have been qualified to comment on her medical condition, it was well within her expertise to opine, based on her ongoing treatment and evaluation, that her disability did not stem from a mood disorder. Dr. Brown has demonstrated through her treatment notes that even with the behavioral symptoms being under control, that she continued to suffer from profound fatigue and related symptomatology to include difficulty focusing and concentrating. Therefore, it should have been evident to Prudential that our client’s disability stemmed from her medical diagnosis of ME/CFS.
It is clear that our client continues to be disabled and her disability stems from her medical diagnosis of ME/CFS. Prudential ignored the relevant medical evidence and relied solely on the biased opinions of its own contracted physician consultants who unlike her treating physicians had never examined or tested her physical, mental, or cognitive functional capacity. Prudential’s biased consultants concluded based solely on a “paper review”, that she had no limitations due to any physical cause and baselessly opined that her disability stemmed from a mental/nervous disorder. It was further stated that her persistent and severe symptoms of CFS which has progressively worsened and impacted her functionality since 2016 would improve with merely a graded exercise treatment protocol. Such claims, however, are unsubstantiated. Plus, it must be noted that graded exercise therapy was removed from treatment protocol by the CDC in 2017 due to inadequate safety and efficacy data.
Ultimately, Prudential and their biased physician consultant’s opinions lacked any factual basis and was clearly unfounded in light of our client’s significant medical history and examination findings. The medical evidence to include the opinions of her “treating” physicians demonstrates that her disabling impairments stem from her diagnosis of ME/CFS. Even in the absence of depression/anxiety, her severe impairments persists. As such Prudential’s application of the 24-month policy limitation for mental/nervous condition was wrong, and our client is in fact eligible for and entitled to continued long term disability benefits under the policy beyond December 30, 2019.
As a result of our appeal, Prudential overturned their termination of benefits and approved her LTD benefits beyond the 24 month limitation.
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