Prudential Overturns Disability Denial for Third Time to Insured with Cluster Headaches

Our client, a former software programmer from Texas, has had a long and tumultuous history with Prudential as it relates to his claims for short and long term disability benefits. With any disability carrier you can never let your guard down, as an approval one day does not mean that benefits will continue forever. In this particular case we have won three different ERISA disability appeals for our client and we continue to represent him on a daily basis.

We Keep Fighting and Our Client Continues to Get Paid

He first contacted Attorneys Dell and Schaefer in 2009 to assist him in appealing the denial of his claim for short term disability benefits. At that time Prudential held that his Chronic Cluster Headaches would not prevent him from performing the duties of his occupation, as all of his symptoms were based on subjective complaints. In preparing the initial appeal for short term disability benefits it became apparent that Prudential was reviewing his medical history as if he had Migraine headaches. Anyone who suffers from Cluster Headaches knows that they are much different than Migraine headaches. Whereas there is a wealth of medical information and treatment options for Migraines, the same cannot be said for Cluster Headaches. Following an appeal submitted by Attorneys Stephen Jessup and Gregory Dell, our client’s claim for Short Term Disability benefits was approved. However, the fight was not over. In evaluating our client’s claim for Long Term Disability benefits, Prudential again issued a denial of benefits.

Prudential Tries To Limit Disability Benefits To Two Years And Claims “Self Report” Symptoms

Attorneys Jessup and Dell again began the process of filing an appeal of Prudential’s denial. Despite the medical evidence already submitted during the course of the short term disability claim, Prudential continued to argue that our client’s Cluster Headaches were based solely on self report and that they should have resolved to the point that he could return to work. It was apparent from the long term disability policy governing the claim that Prudential was arguing this position as the policy contained a two year limitation for conditions deemed to be of “self report.” The Self Reported Symptoms Conditions Limitation in the Policy specifically mentioned “headaches” as an enumerated condition under the limitation. In preparing the appeal it was clear that in fighting on our client’s behalf, we would have to not only prove the debilitating nature of our client’s Cluster Headaches to secure initial benefits but also prepare the claim to be in the best position to overcome the two year self reported symptoms limitation, which would also be further compounded by the two year “any occupation” review that would occur at the same time.

Overcoming the Two Year Limitation of Disability Benefits and a Third Appeal in Within 3 years

Attorneys Jessup and Dell coordinated with our client’s treating physicians and other medical professionals to have our client undergo testing in an effort to provide “objective evidence” of what Prudential deemed to be a subjective condition. Following the submission of the appeal, Prudential approved our client’s initial claim for long term disability. However, Prudential’s decision came with a caveat that benefits would be limited to two years under the self reported symptoms conditions limitation.

After the initial award of long term disability benefits, Attorneys Jessup and Dell began compiling additional medical documentation to submit to Prudential in advance of the two year limitation period. Despite the extensive information that was exchanged back and forth between Prudential and Attorneys Dell and Schaefer, Prudential again issued a denial in advance of the two year limitation period based on our client’s “subjective” condition. Following an in depth review of the voluminous claim file as it existed at the time of this last denial, Attorneys Jessup and Dell immediately began the process of gathering additional medical support and crafting the arguments that would form the basis of the appeal of Prudential’s latest denial.

Following a long appeal review, which included a request for an extension, Prudential again overturned its denial of our clients benefits and deemed him to be totally disabled under the any occupation provisions of the policy, and in doing so conceded that there was objective evidence of our client’s Chronic Cluster Headaches, which removed it from the twenty four month limitations for conditions of “self report.”

Many medical conditions, such as migraines, fibromyalgia, chronic fatigue, etc. are considered to be “subjective” in nature in the opinions of the insurance companies, and as such fall under additional scrutiny and are more susceptible to being challenged. The fact that many insurance companies write specific limitations for these types of conditions creates additional roadblocks to receiving benefits. Over the course of three years, our client had to fight on three separate occasions not only to receive the benefits he was entitled to, but to also prove the existence of his debilitating medical condition. If you are having difficulties with an insurance carrier due to the nature of your medical condition or need assistance in fighting for or keeping your benefits intact, please contact Attorneys Dell and Schaefer for a free consultation.

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