Our client was a Regional Director of Sales for one the largest data processing groups in the world. To say that he was at the pinnacle of his career is an understatement. After knowing a life of work and success in the work place it was a devastating blow when it all came to an end following two Left Capsular Infarctions (Stroke) within several weeks of each other. Despite his best efforts and desire to recover and return to work it soon became apparent that the lingering physical effects of the strokes as well as the effect they had on his memory and cognitive functioning that this would not happen. It was then that he turned to his employer’s short and long term disability policies.
Short Term Disability
Our client made application for short term disability benefits through the Reed Group, a third party administrator hired by his company to evaluate and make recommendations as to approving or denying short term disability benefits. His claim for short term disability benefits was approved and his experience with the Reed Group was relatively benign in comparison to what was to come with Prudential and his claim for long term disability benefits.
Long Term Disability Application
More often than not the same insurance company will review claims for both short and long term disability. This obviously helps keep the claim process between the two stages somewhat continuous. However, as was the case with our client, the fact that two different companies were involved essentially made the process of applying for benefits under the long term disability policy a completely new process. Armed with a plethora of medical records and reports from his doctors that indicated he would not be able to return to his former occupation and the fact his short term disability claim was approved relatively smoothly, it seemed that there would be little trouble in getting his claim for long term disability benefits approved. Unfortunately, Prudential would use every tactic in its arsenal to deny his claim.
The Denial of Benefits
Prudential’s denial letter contained all too familiar language to anyone whose claim has been denied: a lack of “objective evidence” that evidenced “restrictions and limitations” to our client’s ability to perform the duties of his “sedentary occupation.” In denying the claim, Prudential completely ignored the reports of our clients doctors and physical therapists that noted loss of physical and cognitive capabilities following the strokes, and minimized his incredibly demanding job to nothing more than requiring the ability to sit at a desk all day. Prudential completely fulfilled its purpose of adding insult to injury.
Attorney Stephen Jessup was assigned to file the Administrative Appeal on our client’s behalf. Upon receipt and review of the claim file, Attorney Jessup discovered that Prudential relied solely on the opinion of a nurse case manager in denying the claim and that no attempts to speak with our client’s doctors were ever made. In preparing the appeal Attorney Jessup arranged for our client to undergo Neuropsychological testing to document any and all cognitive impairments stemming from the strokes, as well as a full Functional Capacity Evaluation with a board certified Occupational Medicine doctor in order to accurately document the litany of physical impairments that would prevent him from returning to his former occupation. After receiving the reports and test results Attorney Jessup then contacted our client’s doctors to obtain additional letters of support that would completely undermine the review conducted by Prudential’s nurse. Confident in the sufficiency of evidence in support of disability obtained during the appeal process, Attorney Jessup filed our client’s appeal. Faces with an overwhelming amount of information and being attacked as to the subpar review conducted on our client’s claim, Prudential notified our Office prior to the expiration of the 45 day deadline that it was overturning the denial of our client’s claim for long term disability benefits.
Has your claim been denied?
Our client’s story is a reminder that an insurance carrier will attempt to minimize any medical condition in an attempt to deny a claim for benefits in hopes that the insured will not fight back. Depending on your policy you may only have one chance to prove your case before having to file a lawsuit. Do not take an appeal lightly, as failure to properly document your file could have adverse effects on your legal rights. If your claim for long term disability benefits has been denied please feel free to contact our Office to discuss how we may be able to assist you.
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