Prudential Disability Claim Denial is Reversed For Relying on Paper Medical Review to Deny Benefits

This case is another example of Prudential Insurance Company’s unreasonable reliance on paper file medical reviews in order to deny long term disability insurance claims. A paper review means that Prudential will not examine the disability claimant and will either use their own doctor or hire an external doctor to review the claimant’s medical records. Through the use of Pennsylvania disability attorneys, the disability claimant was required to file an ERISA lawsuit in the Pennsylvania Federal District Court. In this case summary we will discuss the Pennsylvania court’s decision to remand Prudential’s denial due to Prudential’s arbitrary and capricious denial of disability benefits.

Background of this Disability Insurance Case against Prudential Insurance Company of America

Michelle Ricca was working for Carlson Holdings, Inc., when she chose to participate in her employer’s Group Disability Insurance Policy, which was issued by Prudential Insurance Company of America.

Ricca was injured in a motor vehicle accident on April 12, 2004, and sustained severe neck and back pain, muscle spasms and other injuries.

Dr. John E. Moskaitis, a primary care physician, treated Ricca from April 2004 to June 2005. Dr. Moskaitis found that Ricca had severe neck and lower back pain, muscle spasms and a reduced range of motion, and diagnosed that she had renal contusions and trapezius myositis. Dr. Moskaitis prescribed pain medications including Vioxx and Percocet, and advised Ricca that she should not lift and use her right hand to grasp or do fine manipulation, and not to use right foot repetitively to operate controls. Dr. Moskaitis’ June 6, 2005 report showed that Ricca received treatment for her neck and back pain, and surgery on both wrists was being scheduled for carpal tunnel syndrome. Her physician concluded that Ricca could not return to work.

On Dr. Moskaitis’ request, Dr. Shanahan performed both EMG and a nerve conduction velocity study on Ricca. Dr. Shanahan noted borderline abnormal difference between the right radial and medial distal latency, which showed a very minimal sensory carpal tunnel syndrome.

On Dr. Shanahan’s recommendation, Ricca participated in physical therapy with NovaCare Rehabilitation from May 2004 to August 2004. Her discharge note reflected that her lumbar spine was better but her neck pain persisted.

Ricca also visited Ms. Hartwell, and her notes revealed Ricca’s frequent complaints of chronic pain that interfered with her ability to drive, sleep and sit comfortably for even brief periods of time.

Dr. James J. Gaul, a neurologist who performed MRI of Ricca’s cervical spine reported that she also had median nerve dysfunction at the wrists bilaterally(carpal tunnel syndrome), which was due to trauma sustained in the accident.

In May 2005, Dr. Young Kim, a pain management specialist who evaluated Rica diagnosed cervical radiculopathy and carpal tunnel syndrome.

Ricca stopped working for Carlson Holdings, Inc., from April 21, 2004 and applied for long-term disability benefits with Prudential at the age of 52.

Prudential’s physical therapist Paula Arbadji andregistered nurse Nora Bargfede, — reviewed Ricca’s medical records of Dr. Moskaitis and Shanahan, notes from Ms. Hartwell and physical therapy records from NovaCare. This internal review found that Rica wasn’t functionally impaired from depression, anxiety or cognitive deficit, but had an acute cervical and lumbar sprain/strain. Prudential initially denied the disability claim without any physician reviewing the disability claim. Prudential concluded that Rica would recover and return to work within a few weeks; and therefore she did not satisfy the 180 day elimination period.

Prudential denied Ricca’s claim on January 17, 2005, determining that Ricca was not disabled under the ‘regular occupation’ definition of the Policy, because she was able to perform material and substantial duties of her regular occupation. Prudential decided that Ricca was not eligible for the benefits as she had not been continuously disabled for 180 days as required by the Policy’s “elimination period”.

Prudential Denied Ricca’s First Administrative Appeal

Ricca appealed Prudential’s initial disability denial and submitted and ERISA Appeal with additional information obtained from Doctors who treated her carpal tunnel condition. Instead of Prudential exercising their right to have Ricca examined by an independent doctor,Prudential decided to do another paper review of her medical records by Dr. William S. Gonte, an external physiatrist.

Dr. Gonte’s report revealed that Ricca sustained minor injuries from the accident and her cervical spine MRI of 2004 and an EMG disclosed median nerve dysfunction at the wrist bilaterally, and her 2005 MRI disclosed progression of the degeneration of the cervical spine. Dr. Gonte concluded that Ricca had pre-existing degenerative cervical changes which weren’t caused or accelerated by the accident. Ricca’s carpal tunnel syndrome appeared to be mild and Dr. Gonte believed that Ricca should have been able to return to work after six months of accident. He believed that there was no supporting data to suggest that Ricca was functionally impaired. Dr. Gonte ignored Ms. Ricca’s complaints of pain.

Based on Dr. Gonte’s paper review, Prudential determined that there was no psychomotor retardation, suicidal or homicidal ideation and cognitive impairments or no supporting data to show that sickness or injury prevented Ricca from performing occupational duties throughout the 180 day elimination period. Prudential therefore denied Ricca’s benefits for the secong time on August 24, 2005.

Prudential Denied Ricca’s Second Administrative Appeal

Ricca filed a second administrative ERISA appeal against Prudential’s denial of her disability claim. In the second appeal, Ms. Ricca provided information that she had been approved for Social Security Disability Benefits. Prudential once again requested Dr. Gonte to review her medical records, but his opinion remained unchanged. Dr. Staurt Shipko, an outside psychiatrist and neurologist, also reviewed Ricca’s records but didn’t examine her. Dr. Staurt Shipko reported that there was no evidence of any psychiatric or cognitive dysfunction. Based on these reports Prudential, on May 8, 2006, denied Ricca’s disability claim for the third time.

Ricca Had No Choice But To File an ERISA Lawsuit against Prudential

After exhausting all her administrative remedies, Ricca filed an ERISA lawsuitagainst Prudential in Pennsylvania Federal Court to recover her long-term disability claim benefits.

The Court noted that Prudential’s denial of Ricca’s long term disability claims benefits was totally based on Doctors’ paper reviews without conducting any physical examination of Ricca.

While determining claim benefits, ERISA plan administrators are not required to defer to the opinions of a participant’s treating physicians. At the same time, the Pennsylvania Court emphasized that ERISA plan administrators can’t arbitrarily refuse to consider a claimant’s reliable evidence, including the opinions of the claimant’s treating physician.

Prudential argued that its assessment of Ricca’s ability to work must be affirmed because the assessment was based on the administrative record and therefore not against the law. Prudential’s physicians and other health care experts never documented why Ricca’s treating physicians’ opinions were discounted or rejected. In its three declination letters, Prudential didn’t explain why or how Ricca’s medical data failed to support injury or sickness within the Policy’s definition of disability.

Relying on the decision in Schwarzwaelder v. Merrill Lynch & Co., Inc., 606 F. Supp. 2d 546 and Elms v. Prudential Ins. Co. of Am., No.06-5127, 2008 U.S. Dist. LEXIS 76917 (E.D. Pa. Oct, 2, 2008), the Pennsylvania Court commented that a plan administrator cannot selectively consider and credit medical opinions without expressing the reasons for doing so, particularly when such opinions favors the employer and consists of non-treating and non-examining experts when there is substantial evidence to contradict such consideration.

As there was a clear conflict between the opinions of experts who treated Ricca and experts who only reviewed her paper medical records without physically examining her, the Court found that Prudential’s decision to accept the opinions and conclusions of its non-examining experts without any explanation was arbitrary and capricious.

The Court determined that Prudential was wrong in denying disability benefits and remanded the case back to Prudential for a thorough and careful analysis of all evidence including the rationale for accepting its experts’ opinion in preference to those of Ricca’s treating and examining health experts. While the claimant won her case at court, she really only won the right to have Prudential review her case again. The court did not rule that disability benefits should be paid, rather the court ruled that Prudential needs to re-evaluate the claim again and provide a more detailed claim decision either for or against awarding benefits. Ms. Ricca has not worked since April 2004, and on September 30, 2010 the court made a decision to give Prudential another chance to review the file. 6.5 years later and this disability claimant still has no idea whether or not she will be paid disability benefits. The Judge had the discretion to award benefits, but unfortunately remanded to Prudential. This case is another example of why ERISA is an unfair law for disability claimants.