Due to his previous employment at DRS Technologies where he worked as an Environmental & Health Safety Specialist, our eventual client was covered under a Long Term Disability (LTD) Insurance Policy with The Prudential Insurance Company of America. This LTD Policy was in place for DRS Technologies’ employees should they be unable to perform the material and substantial duties of their regular occupation or any gainful occupation due to sicknesses or injuries. The policy would pay 60% of the employees’ previously monthly earnings should they satisfy the terms and conditions of this policy.
It was a good thing our eventual client was covered under such a policy because as of May 10, 2012, he was no longer able to “perform the material and substantial duties of his regular occupation.” Forced to stop working due to the physical limitations resulting from spinal stenosis lumbar region, sciatica, lumbago, myalgia and myositis, lumbar radiculitis, postlaminectomy syndrome of lumbar region, postlaminectomy syndrome of cervical region, cervical spondylosis without myelopathy, headache, cervicalgia, status post bilateral L5-S1 foraminotomy and right L5-S1 microdiscectomy, status post anterior cervical discectomy and fusion, our client applied for and was initially approved for LTD benefits by Prudential. LTD benefits began on November 6, 2012, after he satisfied the 180 day elimination period.
Prudential’s First Denial of LTD Benefits
After being paid LTD benefits for the period November 6, 2012 through September 30, 2013, our eventual client was informed by Prudential by way of a letter dated October 14, 2013 that his benefits would terminate as of September 30, 2013. In the aforementioned denial letter, Prudential relied upon a review of its in-house clinical team, the results of a Functional Capacity Evaluation (FCE) it commissioned and Covert Surveillance. Although the results of the FCE provided that our client performed with full effort and had no physical demand/work capacity, Prudential instead decided to rely upon the covert surveillance it had conducted over a three day period two months prior to the FCE.
Apparently because the covert surveillance showed our client “get in and out of two different vehicles”, shopping at a supermarket and a home improvement store, and entering a pizza parlor to pick up a pizza, Prudential felt that the results of the FCE were invalid and that the limited results of the covert surveillance were more compelling. As such, Prudential denied our eventual client’s continued claim for LTD benefits based on the covert surveillance.
Finding Dell & Schaefer
Within a week of being denied continued benefits, our now client contacted and hired Dell & Schaefer to assist him with his administrative appeals to challenge Prudential’s determination. After accumulating updated medical records, the administrative record from Prudential and the covert surveillance, a timely appeal was filed that challenged Prudential’s incorrect decision. Our appeal first focused on how the surveillance was not an accurate measure of our client’s ability to perform his own or any occupation on a full time basis. Furthermore, our appeal noted that Prudential failed to consider compelling medical evidence for the time before, during and after the covert surveillance was performed. Lastly, our appeal challenged Prudential’s decision to completely disregard the Functional Capacity Evaluation it had commissioned with a medical professional of its choosing.
Prudential’s Second Denial of LTD Benefits
Unfortunately for our client, our first attempt at convincing Prudential that its decision to deny was incorrect was unsuccessful. By way of a letter dated June 4, 2014, Prudential informed Dell & Schaefer that it was upholding its previous decision to deny continued benefits. This time Prudential relied upon the paper review of an “independent” physician consultant who specializes in Occupational Medicine. While this physician reviewer found that our client had restrictions and limitations, this physician ultimately sided with the insurance company who hired him. Utilizing this review of a doctor who never treated, evaluated or even laid eyes upon our client, Prudential once again denied our client’s claim.
Dell & Schaefer’s Second Appeal
With the option of filling a second/final appeal or filing a lawsuit, our client, confident in his medical records and file, chose to file an appeal with the hope of avoiding time consuming litigation. Armed with updated medical records and the claim file of the Social Security Administration, who also found our client disabled, a second appeal was timely filed.
Utilizing arguments to challenge Prudential’s “independent” physician consultant’s review, and again challenging Prudential’s reliance upon surveillance, the appeal left Prudential with no choice but to reinstate our client’s claim for LTD benefits.
Within 45 days of the second appeal being filed, Prudential finally came around and agreed that our client deserved to remain on claim. Furthermore, Prudential even agreed that our client was unable to perform the duties of any gainful occupation which meant that our client would continue to receive LTD benefits beyond the first 24 months of his claim.
Although our client was ready to file an ERISA LTD lawsuit against Prudential, he is happy to be reinstated and that Prudential agreed to find him disabled from any gainful occupation. Our client continues to remain on claim to this day and he knows that Attorney Alexander Palamara will continue to do whatever it takes to keep him on claim until he is either able to return to work or until his policy expires.
If you have been denied disability benefits by Prudential or any other disability insurance provider, please do not hesitate to contact the Attorneys at Dell & Schafer for a free consultation.
Read more about Prudential disability claims.