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Prudential Overturns Denial of Benefits on Appeal After Denying Claim On Basis That Insured Failed To Show Medically Supported Restrictions and Limitations

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Mr. P was employed with Kemper Corporation (“Kemper”) when he was diagnosed with severe coronary artery disease and was forced to undergo a quintuple bypass surgery, leading to his total disability and complete inability from performing the material duties of his occupation as an insurance sales manager. Kemper insured all of its full-time employees, including Mr. P, under a group long-term disability insurance plan with Prudential Insurance Company of America (“Prudential”).

Although Mr. P had very much enjoyed working most of his life in the insurance industry, he had never expected that he would be filing a long-term disability insurance claim himself. He was very much surprised at the critical nature of his cardiac condition and under the advice of his cardiologist and other treating physicians he contacted Prudential and notified them that he was advised to stop working by his doctor and would be pursuing a claim for long-term disability benefits.

Once notified Prudential conducted a short interview with Mr. P and informed him that they would be forwarding claim forms to be completed that needed to be completed by him and his physicians. Not wanting to cause any delay, Mr. P, with the assistance of his treating physicians, promptly completed the Prudential claim application and attending physician statements and submitted them to Prudential.

Shortly following receipt of his claim, Prudential began conducting its medical review, which really included nothing more than a review of Mr. P’s medical records and the claim forms that he and his physicians had completed. A short time later Mr. P received a letter from Prudential informing him that his claim had been denied and stating, “based on the review of the medical records and [your doctor’s] inability to comment on your disabling condition, we find you do not have the restrictions and limitations that would prevent work capacity.”

Prudential claimed that they were not successful in receiving a response from one of Mr. P’s treating physicians, giving rise to their basis to deny the claim, despite the fact that Mr. P’s treating physicians had already completed attending physician forms and were fully supporting Mr. P’s claim.

Mr. P contacted Attorneys Dell & Schaefer and retained Attorney Cesar Gavidia to represent him with his appeal of benefits. Attorney Gavidia and his team began the process of gathering all of Mr. P’s medical records. They also created customized medical questionnaires for Mr. P’s treating physicians, specific to Mr. P occupation as an insurance sales manager and his sickness. Attorney Gavidia wanted to leave no doubt in the Prudential Appeal Manager’s mind that Mr. P’s treating physicians supported him and that the medical evidence supported their conclusions and the restrictions and limitations that they had placed on Mr. P.

Shortly after receiving the administrative appeal and the evidentiary exhibits accompanying it, Prudential informed Mr. P’s legal team that it would be conducting a second medical review. After 3 months of reviewing Mr. P’s appeal and the additional evidence submitted by Attorney Gavidia and his team, Prudential finally communicated that it was overturning its previous decision to deny Mr. P’s claim. Prudential would be paying all past due benefits and approving Mr. P’s ongoing claim for monthly long-term disability benefits.

Mr. P is currently on claim and receiving long-term disability benefits from Prudential. Attorney Gavidia and his team at Dell & Schaefer continue to monitor Prudential’s actions, and ensure that all requests for medical documentation and claimant updates are addressed promptly and accurately.



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