Question
Do I only get one appeal with Prudential? Do I have recourse for a STD denial?
Hello. I am wondering if I have any recourse for a STD denial as most of the comments above relate to LTD. I was diagnosed with a reactivation of mononucleosis in April and was out of work for one month, with STD payments the entire time by Prudential. Then in June I began to feel worse again and was taken out of work on June 22, 2014 with mono and an additional diagnosis of Lyme disease. (the Lyme diagnosis was later withdrawn as I didn’t have enough positive bands) Prudential again approved my claim. Then, on August 24th, they stopped paying me. They denied my claim on September 24th and it went to appeal. Today (4:30 on Friday afternoon, of course) Prudential called to say my appeal was denied. Since June, whereas the Lyme diagnosis was withdrawn, I have received additional diagnoses of: fibromyalgia, carpal tunnel syndrome, peripheral neuropathy in hands and feet, osteoarthritis in both hands, high blood pressure, depression, anxiety, demyelinating disease and decrease in memory as well as a transition to “chronic active Epstein Barr” from the plain mono diagnosis. Their denial focused on autoimmune disease tests that came back normal rather than all the ones that came back positive. I have yet to receive my appeal denial letter as apparently the determination was made today or this week sometime. My questions are: Am I done? Do I only get one appeal with Prudential? I was told STD wasn’t covered by ERISA so can I sue? My rheumatologist has me off work for two more months and I am now 12 weeks without pay. Ironically, my doctors have all said that the financial stress placed on me by Prudential is hindering my recovery efforts. I can’t kick the mono. The drugs to help me sleep don’t work well and I wake up exhausted each and every day. My entire body is in pain and I am allergic to pain meds. I can’t pursue the massage and aqua therapy recommended by my doctors because we can’t afford it. I also have a long history of migraines, cervical and lumbar spine issues and chemical sensitivities. My primary concern is whether I have any recourse at all now that my (first) appeal has been denied. Oh and by the way I purchased a supplemental policy through my employer that pays 60% of my salary if I go on LTD whereas the company only pays 50%. I believe they have extra incentive to reject my claim because I purchased the supplemental plan. If I have recourse for the STD denial please advise and I will contact you ASAP. Thanks so much.
Answer
Prudential typically provides a voluntary level of appeal. Following the denial of the appeal you would have the right to bring a lawsuit under ERISA to secure benefits at this time-however, I wouldn’t necessarily suggest that at this time as the rules for litigation under ERISA are very restrictive. If your appeal did not provide adequate evidence of disability due to your diagnoses and you were to file a lawsuit now, under ERISA you would not be allowed to supplement the administrative record with additional information. Please feel free to contact our office to discuss how we may be able to assist you.
