Our client, Mr. T, formerly worked as a Nuclear Medicine Tech for a large hospital. In May 2011 a number of medical issues, chronic pain syndrome, cervical spine degenerative disc disease, cervical radiculopathy and neuropathy forced Mr. T to stop working and submit his claim for disability benefits first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by Prudential Insurance Company of America (Prudential). Under his employer’s disability policies Mr. T would be considered totally disabled after 24-months if he was unable to perform the material and substantial duties of any gainful occupation, which was defined as any occupation he was qualified to perform by education, training and experience and considering any/all documented functional restrictions and limitations.
After paying Mr. T for more than 3½ years under the LTD Policy, Prudential denied further LTD benefits on the basis that he allegedly no longer met the policy definition of disability. Specifically, Prudential determined that “the medical information received did not support impairment that would prevent [him] from performing the material and substantial duties of any gainful occupation.” After receiving the denial, Mr. T contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Prudential’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. T’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Prudential’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Prudential’s denial and significant inconsistencies with its medical reviewer’s findings. The appeal next addressed the fact that Prudential’s denial letter grossly misstates and mischaracterizes the record evidence regarding communications between its 3rd party medical consultant (Consultant) and Mr. T’s primary treatment provider. In particular, Prudential claimed that Mr. T’s physician offered a signed agreement with its Consultant’s opinion that Mr. T had light work functional abilities yet the undisputed medical evidence confirms the exact opposite. The appeal also addresses the fact that despite acknowledging Mr. T suffered from twenty-five (25) chronic medical conditions and despite having never examined or observed Mr. T, Prudential’s Consultant assigns to him functional capabilities far in excess of any of his treatment providers or Prudential’s own prior medical reviewer, who concluded that “the claimant had multiple medical conditions when taken individually and in total render him functionally impaired from sustaining even a part time sedentary capacity.” Finally, the appeal addressed the fact that Prudential did not comply with its obligations under 5th Circuit and Supreme Court precedent by failing to meaningfully address Mr. T’s award of Social Security Disability benefits.
Approximately nine weeks later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Prudential overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. T’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that Prudential will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.