Our client was a former public school teacher in South Florida who was forced to file for long term disability benefits under her school district’s disability policy with Prudential due to debilitating Chronic Pain stemming from multiple disc herniations in her neck and lower back and osteoarthritis of the knees. Like the vast majority of Prudential disability insurance policies our client’s policy contained a two year “regular occupation” definition of disability that would pay benefits in the event she was unable to perform the material and substantial duties of her occupation as a school teacher. Then after long term disability benefits had been paid for 24 months the definition of disability changes to the stricter, “any gainful occupation” definition of disability.
Following the submission of an application for benefits, Prudential approved our client’s claim under the regular occupation definition of disability with little difficulty. After 24 months of payments Prudential then conducted its review as to our client’s entitlement to benefits under the any occupation standard of disability and upon completion of same determined our client to continue to be totally disabled from performing the duties of any gainful occupation based on the overwhelming amount of supportive medical evidence.
The Denial of Benefits
For over two years Prudential continued to provide continued monthly disability benefits to our client under the “any gainful occupation” definition of disability. Needless to say our client was not concerned about Prudential denying her claim, based on the fact that Prudential had never denied her claim for benefits and she was receiving her Social Security Disability benefits. Then, after being on claim for four years, without warning she received a letter from Prudential which stated that based on a review of her records she would not be precluded from returning to her former occupation as a school teacher and that in addition to being able to return to her former occupation that she would be able to perform a multitude of other less physically demanding occupations.
Appealing Prudential’s Denial
Our client contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup to discuss what could be done to get her benefits reinstated. Review of Prudential’s claim file indicated that the medical review conducted by Prudential was relegated to a limited review of medical records from only a few of our client’s treating physicians, and focused solely on her knee conditions while ignoring the abundance of medical information relating to our client’s back and neck conditions. In doing so Prudential had an easy job of arguing our client could perform full time sedentary work and in turn denying her claim. Attorney Jessup attacked Prudential for failing to conduct a full and fair review of our client’s file as required by ERISA. Knowing that pointing out Prudential’s flaws would not in and of itself make Prudential admit it’s error in denying benefits, Attorney Jessup arranged for our client to undergo an IME and Functional Capacity Evaluation to fully document her physical restrictions and limitations. Armed with objective testing to establish our client’s physical ability to work Attorney Jessup systematically proved that our client could not perform the duties of her prior occupation as well as the alternate occupations Prudential claimed she was capable of performing.
Within the 45 days allotted to render a decision following the filing of the appeal, Prudential notified our Office that it was overturning the denial of our client’s claim, reinstating her benefit and forwarding all back benefits owed.