Prudential denies disability benefits despite FCE Exam stating former Data Distributor Inc. employee with heart condition cannot perform sedentary occupation
A disability attorney recently filed a long term disability lawsuit due to Prudential Insurance Company’s wrongful denial of disability benefits to a former project manager. This case shows that despite strong objective evidence and a positive FCE exam in support of multiple disabling conditions, Prudential can still hire physicians that can review a file and determine that a claimant has no restrictions and limitations.
The Facts of the Prudential Disability Denial
The plaintiff as part of his employment benefits with Data Distributors Inc as a project manager, was a participant in a life insurance plan as well as a long term disability plan that was insured and administered by Prudential. The plans are said to be governed by the Employee Retirement Income Security Act (ERISA).
The plaintiff stated in the lawsuit that he stopped working for Data Distributors on or around August 4, 2009 as he was suffering from multiple heart problems and shortness of breath. His medical diagnosis consists of ischemic cardiomyopathy, diabetes, hypertension, systolic heart failure, hypercholeserolemia, hypertriglyceridemia, status post ICD, low back problems, left knee problems and left elbow problem.
Termination of Disability Insurance Benefits
After filing for a claim for long term disability benefits, Prudential initially approved the plaintiff’s claims for long term disability benefits as well as a life insurance premium waiver. Prudential, however, terminated the plaintiff’s disability benefits and waiver of premiums on June 30th 2010.
Prudential denies two ERISA Appeals submitted by Claimant
On July 28th 2010, the plaintiff submitted his first administrative appeal to Prudential. As part of the administrative review process, Prudential requested MES, a medical review company, to review the plaintiff’s medical records. The plaintiff contended that MES requested an internist to review the records and render an opinion. The internist, however, concluded that the plaintiff could handle the duties of up to a light duty occupation, which consisted of lifting up to twenty (20) pounds of force occasionally and negligible force frequently for lifting, carrying, pushing and pulling.
On September 1, 2010, Prudential denied the plaintiff’s administrative appeal resulting in the plaintiff submitting another appeal on February 21st 2011. To support his appeal, the plaintiff included a functional capacity evaluation (FCE) which indicated that the plaintiff did not meet the lifting and sitting requirements required of a sedentary occupation. The plaintiff’s treating physician, a cardiologist, also opined that the plaintiff was unable to perform the material and substantial duties of his regular occupation.
In its review process, Prudential assigned MLS, another medical review company to review the plaintiff’s records. The review concluded that the plaintiff would be able to handle a sedentary workload capacity but indicated a VO2 max stress test (done for standing and walking) should be done to better assess the plaintiff’s cardiovascular issues. The review also opined that the plaintiff did not give a true effort on the functional capacity evaluation and determined that many of the activities performed in a sedentary office occupation would not require repetitive lifting from floor to waist and waist to the level of the scalp. The plaintiff stated in the lawsuit that none of the plaintiff’s treating physician and therapist were consulted during the Appeal review process. Hence, on May 27th 2011, Prudential denied the plaintiff’s second administrative appeal.
Legal Basis for Lawsuit against Prudential
The plaintiff alleged that Prudential’s decision to deny his claim for long term disability benefits was unreasonable, arbitrary and capricious due to the following reasons:
- Not contacting or trying to contact the plaintiff’s treating physician and therapist that conducted the FCE to see why their respective opinions differed from Prudential’s medical reviewers’ opinions.
- Over reliance on the medical reviewers’ opinions, especially the medical reviewer’s opinion indicating a VO2 max stress test for standing/walking was the appropriate test measure and subsequently not advising the plaintiff to obtain said test and not scheduling said test with a physician of Prudential’s choice.
- Possibly not evaluating the plaintiff’s claims according to Prudential’s own policies and procedures.
- Indicating that the plaintiff did not give a full effort on the FCE when in fact the functional capacity evaluator believed the plaintiff gave maximal effort on all test items.
- By relying on a medical reviewer’s opinion that sedentary work did not include lifting from floor to waist and waist to crown level.
- By ignoring or diminishing the results of the FCE and the plaintiff s treating physician’s opinions.
Relief Sought by the Plaintiff
As a result of Prudential’s actions, the plaintiff is seeking from the Court the following relief:
- Disability benefits due to him.
- Prejudgment interest.
- Attorney fees.
- Expenses of the litigation.
- A waiver of life insurance premiums.
- Court costs.
- Any further relief that the Court deems just and proper.
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