Alan, a 56 year old welding foreman was forced to stop working due to severe neurological symptoms stemming from polycythemia vera, recurrent seizures and hemochromatosis. Prudential initially approved Alan’s claim, but later terminated his benefits stating that he was purportedly capable of performing the duties of his regular occupation as a welding foreman.
Alan symptoms included partial complex seizurs and generalized ton-clonic seizures, weakness, fatigue, headaches, lightheadedness, shortness of breath, visual disturbances, leg pains, itching, periods of confusion and tinnitus. Alan’s doctor prescribed scans of his brain including an electrocephalogram (EEG). The EEG study demonstrated abnormal results, showing that Alan experienced a total of 16 push-button events. Alan’s treating physicans determined that his seizures were non-epileptic, and coupled with his diagnosis of polycythemia likely represented hyperviscosity syndrome.
Hyperviscosity syndrome is a condition in which blood isn’t able to flow freely through your arteries. You may have arterial blockages due to too many red blood cells, white blood cells, or proteins in your bloodstream. This syndrome is most common in infants and children. It can affect their growth by reducing blood flow to vital organs, such as the kidneys and brain.
Despite its awareness of Alan’s blood disorder and neurological symptomology, and despite its agreement that Alan’s restrictions included no working at heights, around heavy machinery or climbing ladders, Prudential terminated Alan’s claim within six months of approving it.
Alan retained Attorney Cesar Gavidia of Dell and Schaefer to appeal and address Prudential’s termination of benefits. After spending 5 months reviewing the 146 page appeal submitted by Attorney Gavidia and his team, Prudential overturned its decision and reinstated benefits, as well as paid all back benefits owed. However, the problem with Prudential’s decision to overturn Alan’s claim was that despite receiving overwhelming medical evidence that Alan’s symptoms stemmed from a disabling blood and neurological disorder, Prudential and its medical consultants arbitrarily and wrongfully concluded that Alan’s disabling condition is contributed in whole or in part to somatoform disorder, a psychiatric condition subject to the Prudential long-term disability policy’s 24 month mental illness limitation. The insult to the injury is that although Alan suffers from depression, he does not suffer from somatoform disorder, nor has he ever been treated for the condition. It is diagnosis completely made up by Prudential and its medical consultants to attempt to limit their exposure to 24 months of benefit payment.
Alan, Attorney Gavidia and his team vow to continue fighting Prudential and will not only be appealing Prudential’s partial adverse benefit determination, but also pursue all legal remedies available under ERISA should the fight continue beyond the administrative appeal level.