Since 2001, Prudential Insurance Company of America has approved and denied the long term disability benefits of Donna Elms on numerous occasions. Despite the approval of SSDI benefits and support from her treating physicians, Prudential wrongfully denied disability benefits. This case is a classic example of the continuous difficulties that a disability company can give a claimant throughout the duration of their disability claim. Fortunately, Ms. Elms did not give up and was successful in making Prudential pay her the disability benefits she was owed. Let’s take a closer look at the Ms. Elms’ 8 year battle with Prudential.
Donna M. Elms, a 43 yr. old Human Resources Assistant, was involved in a motor-vehicle accident on January 31, 2001. She went immediately to a chiropractor who diagnosed her with an acute cervical sprain which quickly developed into cervical neuritis. Upon his recommendation, she did not return to work until February 12, 2001, and when she did her doctor placed light duty restrictions upon her workplace activities.
In June of 2001, Elms began seeing a different chiropractor. This chiropractor ordered an MRI of both her cervical and lumbar spine. The MRI revealed that there was minimal disc bulging at C5-6 and C6-7, and mild bulging at the L4-5 disc. He recommended that she go to see a neurologist. Elms did so. After his exam, the neurologist concluded that she was suffering from a brachial plexus injury and possible lower extremity nerve damage. He advised that she stop working immediately. She did so.
As an employee at Diebold, Inc., she participated in a long-term disability plan administered by Prudential Insurance Company (Prudential). Elms applied for long-term disability benefits. According to the definition of the disability in her policy she needed to prove that she was unable to perform the material and substantial duties of her occupation.
On December 27, 2001, Elms neurologist submitted an attending physician’s statement. In it, he reported that Elms had developed brachial plexus and lumbrosacral plexus injuries from the accident. He reported that she was unable to use her arm, sit, or walk. As a result, he concluded that she was unable to work. In a separate report, the neurologist stated that Elms’ “brachial plexus injury and RSD (reflex sympathetic dystrophy syndrome)” were stable.
On December 28, her chiropractor also provided a similar diagnosis. He noted that she was suffering from lumbar and cervical disc protrusion, cervical, thoracic and lumbar sprain/strain, cervical and lumbar radiculitis, brachial plexus injury and lumbrosacral plexus traction injury.
Elms had also gone to see an orthopedist who noted the sprain of her lumbrosacral spine and disc bulging as reflected in the MRI. He observed that she had no herniations. At the same time, he noted that he did not have an answer for why she was suffering so much pain and discomfort.
Initially, on March 25, 2002, Prudential determined that Elms was not eligible for long-term disability benefits. The denial letter failed to include a description of her job, and incorrectly identified her position as a “senior secretary”. Prudential pointed to the fact that her position was predominantly sedentary in nature, and claimed that she had not provided any medical documentation that supported impairment from performing in a sedentary position.
On June 12, 2002 Elms submitted an ERISA appeal. She corrected their misconception that she was a senior secretary. She noted that she was a human resources assistant, and that the position was far from sedentary. Her position required her to lift and walk frequently. She also was required to travel up to six times a year. She also pointed to the fact that she was suffering from nerve damage, not just bulging discs.
She supported her appeal by including evidence that she had been awarded benefits by the Social Security Administration. She also included an April 26, 2002 report from her neurologist who reported that her cervical and lumbar disc bulging and brachial and lumbar-sacral plexus traction injury had worsened. He had upgraded her diagnosis to RSD. He noted that he had never seen a case of RSD reverse at the state she had reached.
He noted that her “pain, hyperalgesia of the skin, inability to move her left arm and diminished movement in her leg” due to the extreme pain she suffered were conditions that were not going to go away. He noted that she was unable to drive or do her own housework, and for this reason he concluded she would not be able to work either.
Diebold submitted a job description to Prudential to assist it with its review. The human resources assistant position required sitting most of the day, using a computer, and numerous administrative responsibilities, including answering the phone.
Prudential completed its review on October 7, 2002. It reached the conclusion that Elms’ initial musculoskeletal complaints had intensified into a neurological condition – brachial plexus traction injuries and RSD. The long-term disability plan concluded that she had been impaired during the entire elimination period, and approved her for disability benefits up to the date of April 26, 2002.
In order to demonstrate that she was still disabled, Prudential requested Elms to undergo an independent medical evaluation (IME). She did so on February 6, 2003. The neurologist who examined her confirmed that she did have a brachial plexus traction injury of the left side, cervical strain, lumbar sacral strain, and evidence of spasms. He did not confirm the RSD diagnosis. He concluded that the amount of pain and spasms that she suffered would make it generally impossible for her to work even in a sedentary position. He recommended that she should undergo aggressive physical therapy, and recommended injections to treat her pain. It was his conclusion that if she followed his recommendations she would be able to return to a sedentary/light-duty position within 3 to 6 months.
Elms’ treating neurologist disagreed with the course of treatment suggested. He claimed that the course of treatment would aggravate Elms’ RSD. It was his recommendation that she not pull, push, lift or carry, because any of these activities would worsen her pain and the RSD.
In light of this information, Prudential reversed its decision to deny long-term disability benefits and approved Elms for benefits in October 2003.
On August 5 and October 15, 2004, Prudential requested that Elms supply additional documentation to confirm her continuing disability. Elms failed to respond to these requests. A final request was sent on January 13, 2005 giving her until February 13, 2005 to complete the forms the disability insurance company was requiring. When the forms were not received by February 17, Prudential terminated Elms’ long-term disability benefits. Four days later, Prudential received a completed attending physician statement from Elms neurologist, and a statement filled out by Elms. She notified Prudential on March 22, 2005 that she was appealing Prudential’s decision to terminate her benefits.
The attending physician statement that Prudential received on February 21 stated that Elms was suffering from lumbar strains, lumbar plexus, traction injury, and Causalgia. Her neurologist noted that her nerve damage had converted to Causalgia. He noted that Elms suffered from the following limitations: She could not sit, stand, or walk for long periods of time. She could not lift, pull, push or carry anything.
Prudential sent Elms’ file to its medical director to review. The medical director concluded that her medical records reflected her ability to lift up to 10 pounds occasionally, but recommended no overhead activity or repetitive pushing or pulling. After reviewing Elms’ job duties at Diebold, the claims handler concluded that she should be able to answer telephone calls, provide support for presentations, make travel arrangements, perform word processing duties and other computer work, prepare mail and travel occasionally. Prudential upheld its decision to terminate Elms’ long-term disability benefits on June 27, 2005.
Elms appealed a second time on December 20, 2005. She argued that her condition had not improved and that her job duties were inaccurately characterized. She pointed to the fact that she continued to suffer from brachial plexus injuries and RSD. She did not supply any additional records with her December 20 letter, but she did so when she completed her appeal on May 1, 2006. She included her latest medical records from her neurologist and an additional physician, who interpreted her MRI results.
Prudential sent her file to a neurologist for a file review. He concluded that she had been functionally impaired from February 18, 2005 forward, but he expressed his opinion that her impairment could be accommodated within the workplace. He concluded that she would be able to work continuously in a sitting position, that she would require repositioning every hour, and that she would only be able to walk or stand occasionally. He concluded that she would be able to lift or carry as long as the weight was restricted to only 10 pounds occasionally. And he concluded that she would be able to reach up to 18 inches as long as it was on an occasional basis. He also concluded that gripping, grasping, pinching and performing repetitive and fine motor activities had to be limited to occasional activities.
His final conclusion was that these limitations would be temporary, and should resolve themselves within the next 12 months if she continued with further treatment from her treating physicians.
Prudential upheld its decision to terminate Elms long-term disability benefits on July 26, 2006. It pointed to the conclusions drawn from both of its file reviews that Elms was capable of working in her own sedentary position as a human resources assistant.
Elms disability attorney filed a lawsuit governed by ERISA In The United States District Court For The Eastern District Of Pennsylvania federal court. This gave rise to the issue of which standard of review applied to her claim. Did language in the Prudential policy give Prudential discretion?
The District Court reached the conclusion that no, the policy did not give Prudential discretionary authority. It would use the de novo standard of review. At the same time, the Court would also review Prudential’s decision using the arbitrary and capricious standard of review, even though prior court rulings had favored using the de novo standard when policy language matched Prudential’s.
Under the de novo standard of review, the Court would consider whether or not Prudential had made the correct decision in light of the evidence presented by Elms regarding for disability. Under the arbitrary and capricious standard of review, the Court would have to consider whether Prudential made a reasonable decision.
In this case, Prudential was unable to demonstrate that it made either the correct decision or a reasonable decision. Prudential had originally found Elms was disabled based on her diagnosis of brachial plexus injuries and RSD. Her condition had worsened, yet it appeared that Prudential’s physicians had overlooked the fact that causalgia was a diagnosis given when RSD became more severe. Rather than Elms’ condition having improved, it had become worse. Yet Prudential had chosen to affirm its termination of her long-term disability benefits.
The Court also found that it was impossible to compare the limitations imposed by her brachial plexus injuries and causalgia with her required job duties and not find that she was unable to perform the required duties of a human resources assistant. She was restricted to only performing repetitive and fine motor activities occasionally, yet her position required frequent repetitive tasks.
Several factors connected with an arbitrary and capricious review also worked against Prudential. There had been procedural irregularities that demonstrated bias:
- reversing an LTD benefit decision without additional medical evidence;
- selectively using and interpreting physician reports in a self-serving way;
- disregarding a staff recommendation that benefits be awarded; and
- requesting a medical examination when all the evidence supplied already indicated disability.
Prudential had also ignored the opinions of her treating physicians for no apparent reason. It also ignored an opinion rendered by its own independent medical examiner. When the Court asked the pertinent question under arbitrary and capricious review, “What changed?” It determined that nothing had changed. Even Prudential’s final file review noted that Elms’ activities were significantly restricted.
Whether the Court applied the de novo standard of review or the arbitrary and capricious standard of review, Prudential’s decision to terminate Elms’ long-term disability benefits was neither based on sufficient evidence nor was the decision reasonable. Elms’ ERISA attorney’s motion for summary judgment was granted. Prudential would have to reinstate Elms’ long-term disability benefits.