Our client, a chiropractor in a busy New York practice, ceased working at the suggestion and advice of his doctors due to his complaints of shoulder and neck pain that was resulting in radiating pain into his arm and severely affecting his range of motion. He in turn filed his claim for long term disability benefits with Prudential under a disability insurance policy he had purchased through the National Business Association for Chiropractors. Despite support from his doctors that he would be prevented from performing chiropractic medicine, Prudential’s “clinical team” determined that there was insufficient medical evidence to support a loss of physical function that would have prevented him from working, and further noted that he had worked with these conditions to some extent since 2012 and as such should not be restricted from working as of the time of his claim.
Disheartened by the denial, our client did not take any action on filing an appeal of the denial until there was less than a month to submit his appeal. At that time he contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup. In reviewing the denial letter and the policy it was immediately clear that Prudential was essentially treating our client’s claim as one that would be governed under ERISA- the body of law that applies to employer provided disability policies. However, our client’s policy did not fall under ERISA as he was not an employee of the National Business Association for Chiropractors, nor was it a true individual disability policy, instead it was an Association/Franchise policy, which fell outside of ERISA and in doing so functioned more like an individual disability policy. In treating his policy like an ERISA disability insurance policy Attorney Jessup believed that Prudential’s review was far from thorough and was more concerned in establishing our client had the ability to work at a sedentary or light duty demand level rather than actually reviewing the material and substantial duties of his occupation as a Chiropractor.
Attorney Jessup argued in the appeal that our client’s ability to perform normal daily activities were in no way an accurate reflection of his ability to perform the duties of that of a Chiropractor, which are by their nature very physically demanding. In addressing Prudential’s argument that there was a lack of evidence of functional limitations Attorney Jessup had our client undergo a Functional Capacity Examination in order to objectively verify our client’s subjective complaints of pain, as well as his physical restrictions and limitations. The results of the FCE verified what our client had held all along- that he would be unable to perform the physically rigorous duties of his occupation on account of his medical conditions. Attorney Jessup then sent our client’s doctor a detailed attending physician’s statement to further establish and support our client’s physical functional restrictions.
Despite the very limited amount of time left to file the appeal when our client contacted our office, Attorney Jessup was able to prepare and submit an appeal containing new, supportive evidence of restrictions and limitations. Following review of the information provided, Prudential notified our office that it was approving our client’s claim and forwarding all back benefits owed.
If your claim for disability insurance benefits has been denied, or you have questions pertaining to your disability claim, please do not hesitate to contact our office to speak to one of our disability insurance attorneys.