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.


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Prudential

Denied but Not Denied but I am Denied

Reviewed by KDDK on July 5th 2024   Verified Policyholder | August 2022 date of disability
I went out in Aug. 2022 for neck pain. After seeing a neurologist I had to get an ACDF C5-7, it was also determined I had carpal tunnel in my right hand and bulging disk i... read more >
Prudential

California State Disabilty "OFFSET" never mentioned or outlined when enrolling for STD coverage.

Reviewed by MartyG on June 29th 2023   Verified Policyholder | May 2023 date of disability
All terms and conditions of receiving a claim benefit not made available when enrolling. Hidden elements of eligibility... not fully transparent with issues that might eff... read more >
Prudential

Prudential terminated my LTD, so now I have no income

Reviewed by Carlos M on June 10th 2022   Verified Policyholder
I was working at a shipyard at San Diego and hurt my back again while working. Hurt my back in the US Navy in 98 and had issues since then so I decided to get the surgery ... read more >
Reply
Sent on June 11th 2022 by Attorney Rachel Alters

Carlos, yes we may be able to help. Please email your denial letter to Rachel@diattorney.com and cc Amanda@diattorney.com. Thank you.

Prudential

Prudential cancelled my policy amid COVID crisis

Reviewed by Patricia M. on September 15th 2020   Verified Policyholder
In the mist of the covid crisis Prudential decided I needed to prove my disability, yet again. I have been physically disabled since 10/31/1989. I now know that I have bee... read more >
Reply
Sent on September 15th 2020 by Attorney Jay Symonds

Patricia: This is a terrible situation. You likely have a right to appeal the decision. I suggest you contact our office and speak with one of the attorneys to discuss ... read more >

Prudential

I was sold a policy that I cannot use and no one will show me the policy

Reviewed by Jacqueline G. on August 18th 2020   Verified Policyholder
I had Prudential STD and LTD through my employer. I received my STD with no problem. Started receiving LTD for a while, then Prudential said I owed them because I receive ... read more >
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Sent on August 18th 2020 by Attorney Stephen Jessup

Jacqueline, in many cases a disability carrier cannot offset for SSDI benefits that were in place prior to the date of disability under the applicable policy. Your empl... read more >

Prudential

Prudential verbally approved my claim and then sent me a denial letter

Reviewed by Jacquieline C. on April 3rd 2020   Verified Policyholder
I have been denied twice from Prudential for my LTD case. Back injury 2009 – knee injury 2011. Back doctor took me out of work (July 2018) due to me working 35 hrs per w... read more >
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Sent on April 3rd 2020 by Attorney Jay Symonds

Jacqueline: Sounds like you have a pretty complex medical situation. And the fact that they verbally approved your claim over the phone then sent a denial letter is unu... read more >

Prudential

It would cost me more to fight Prudential than to let them get away with their games

Reviewed by Tim W. on December 9th 2017   Verified Policyholder
I’ve been thru all the same things everyone complains about here. I’ve always been one step ahead of their game due to research. I just got notice they are stopping my... read more >
Prudential

Prudential told me I would have a decision today, and now the need another week. Guess what, I'm still broke

Reviewed by Cancer Patient on June 22nd 2017   Verified Policyholder
Just called them and now they need another week and a half so they can do an occupational review on my job description or something like that. Even though the case manager... read more >
Reply
Sent on June 22nd 2017 by Attorney Stephen Jessup

DL, many state insurance commissioners will not get involved in ERISA governed disability insurance policies as these polices are governed under federal law. Please fee... read more >

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We are disability insurance attorneys that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.

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Our clients include all types of employees ranging from retail associates, sales representatives, government employees, police officers, teachers, janitors, nurses, pilots, truck drivers, financial advisors, doctors, dentists, veterinarians, lawyers, consultants, IT professionals, engineers, professional athletes, business owners, and high level executives.

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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.

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