Prudential Insurance Company of America overturned previous denial of long term disability benefits for Oregon Software Engineer
Author: Attorney Jay Symonds
Our client, Mr. B, formerly worked as a Software Engineer for an International Software Corporation. In November 2014 a number of issues including chronic bipolar disorder, schizoaffective disorder, short term memory loss, and obstructive sleep apnea forced Mr. B to stop working and submit his claim for disability benefits first under his employer’s self-funded short term disability (“STD”) plan administered by Prudential then continuing under his employer’s Long-Term Disability (“LTD”) Policy administered and funded by Prudential. Under both of his employer’s disability policies Mr. B would be considered totally disabled if he was unable to perform the material and substantial duties of his regular occupation, which was defined as the occupation he was routinely performing when his disability began.
After paying Mr. B for more than 7 months 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 Mr. B “had not provided sufficient proof to establish that he was unable to perform his regular occupation.” After receiving the denial, Mr. B 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. B’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. The appeal next addressed the fact at the time Prudential discontinued benefits effective January 2016 there was more than sufficient medical evidence contained in the claim file and submitted by Mr. B’s physicians to support his ongoing claim for benefits due to his diagnosed condition(s) of chronic obstructive sleep apnea/narcolepsy. The medical records submitted clearly establish that Mr. B was under the regular care and treatment of a Board Certified Neurologist for chronic sleep apnea/narcolepsy since 2009. And those records clearly establish that Mr. B suffered a myriad of symptoms associated with his conditions. What’s more, although required for a full, fair and thorough review of Mr. B’s claim, neither the claims examiner nor the medical consultant conducted or provided a detailed assessment of the available medical records, especially those around the time Prudential denied Mr. B’s claim. The claim file also confirmed that no attempt was made by Prudential to contact Mr. B’s treatment providers to determine the nature and extent of his restrictions and limitations. And finally, the claim file confirms that Prudential failed to consider a fully supportive and comprehensive Neuropsychological Evaluation conducted on Mr. B just months before the denial.
Nearly four months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records as well as the expert reports, Prudential overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. B’s LTD claim. 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.