Our client, Mr. D, formerly worked as an Audit Manager for a large, international heating and air conditioning manufacturer. In September 2013 a number of psychiatric issues, including PTSD, bipolar disorder and major depression forced Mr. D 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). Mr. D’s LTD Policy had a 24 month maximum benefit limitation on psychiatric disabilities. Consequently, after 24 months of LTD benefits, Mr. D would continue to be considered totally disabled if he was unable to perform the material and substantial duties of his own regular occupation solely as a result of a physical sickness or injury, separate and independent of any ongoing psychiatric conditions from which he may suffer.
In March 2016, after paying Mr. D for 24 months based on his psychiatric conditions, Prudential denied continued LTD benefits on the basis that Mr. D he allegedly no longer met the policy definition of disability. Specifically, Prudential stated that his physical “restrictions and limitations [were] within the physical demands of [his] regular occupation.” After receiving the denial, Mr. D 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. D’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. In support of the appeal, Attorney Symonds submitted an Attending Physician’s Statement (APS) from Mr. D’s Infectious Disease physician – with whom he had treated for more than 13 years – as well as his Cardiologist – with whom he had treated with for more than 15 years. Both physicians stated unequivocally that Mr. D’s physical illnesses and ailments prevented him from performing the material and substantial duties of his regular “light capacity” occupation or, for that matter, any sedentary occupation. The appeal also points to the fact that, despite Mr. D’s many complex conditions and treating specialists, Prudential’s denial rested on a records review conducted by an in-house medical consultant with little clinical experience and board certified in Occupational Medicine. Finally, the appeal addressed the fact that Prudential made no attempt to determine whether Mr. D could actually perform his “regular occupation.” Rather it relied on a generic job description from Mr. D’s employer which was less than a single page and attempted to encompass the full scope of Mr. D’s “essential duties and responsibilities” in just nine (9) single sentence bullet points. And nowhere did it discuss or mention the physical requirements of Mr. D’s job. The appeal established that when compared to Mr. D’s actual duties and responsibilities, which were clearly quite intellectually complex, detail oriented and more physically demanding than simply “light” work, Prudential’s purported investigation was incomplete and unreasonable.
Less than four (4) 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. D’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that Prudential will not terminate his benefits again.
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