In 2014, our client, Michael, received the terrible news that he had squamous cell carcinoma of the alveolar ridge (Mandibular Cancer), and as a result was forced to cut a successful career as a financial advisor with JP Morgan Chase short. While undergoing extensive surgery on his jaw with flap reconstruction, treacheostomy and post-operative radiation therapy, Michael submitted his claim with JP Morgan Chases’ long-term disability insurer, The Prudential Insurance Company of America (“Prudential”).
The Prudential policy qualified disability as:
You are disabled when Prudential determines that:
- You are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and
- You are under the regular care of a doctor; and
- You have a 20% or more loss in your monthly earnings due to that sickness or injury.
- After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury;
- You are unable to perform the duties of any gainful occupation for which you are reasonably fitted by educated, training or experience; and
- You are under the regular care of a doctor.
After submitting his disability claim, Prudential reviewed Michael’s Claimant Statement, Attending Physician Statement and the medical records provided by Michael’s treating physicians. Within a few weeks of the claim being submitted, Prudential approved the disability claim and Michael began receiving disability benefits.
Unfortunately, Michael not only lost a rewarding career that he loved, but also the ability to fully open his jaw, restricting his ability to eat and chew, and required the use of a PEG feeding tube in order to receive much of his nutrition. He lost multiple teeth due to his condition, as well as his ability to communicate effectively, a critical aspect of his occupation as a financial advisor.
Prudential’s Terminates Long-term Disability Benefits Finding That Financial Advisor Can Work in a Gainful Occupation.
After paying 24 months of long-term disability benefits, Prudential notified Michael that he no longer met the definition of “disability” in the long-term disability policy and that it felt he could work in a sedentary occupation. In its denial letter, Prudential identified four occupations it believed he could perform.
Prudential alleged that Michael could purportedly perform the occupations of financial representative, sales account manager, financial planner and registered financial representative.
After receiving his letter denying his claim for any gainful occupation benefits, Michael retained Attorney Cesar Gavidia and his appeal team at Attorneys Dell & Schaefer.
In the Appeal, it was argued that all of the occupations identified by Prudential in its denial letter required significant and effective verbal communication. In the Appeal, Evidence from the Department of Labor was submitted confirming that the occupations identified by Prudential all required the unencumbered ability to “speak clearly so that the listener would understand” and the ability to “communicate information and ideas in speaking so that others would understand.”
It was further argued that in baselessly denying Michael’s long-term disability claim, Prudential also failed to account for the psychosocial impact that his language limitations and significant facial disharmony would impose.
Within 4 weeks of the Appeal being submitted, Prudential notified Attorney Gavidia and Michael that the adverse decision it had previously made was being overturned and that he indeed qualified for disability from Any Gainful Occupation for which he was qualified based on education training and experience.
Michael continues to receive long-term disability benefits from Prudential, and unfortunately remains disabled. Attorney Gavidia and his team at Dell & Schaefer continues to represent Michael in his claim and monitor all of Prudential’s activity closely.