Prudential reverses denial of long term disability benefits to engineering manager suffering from coronary artery disease
Author: Attorney Gregory Dell
Our client, an Engineer Manager specializing in Fluid Power Engineering, suffers from severe Coronary Artery Disease. Despite the fact multiple diagnostic tests performed indicated there were no abnormalities with his heart, he suffered two heart attacks in the span of six months. Following his second heart attack in July 2006, he applied for long-term disability benefits under his employer’s long term disability plan through Prudential. Prudential initially approved his claim for disability benefits, and following his elimination period he began receiving long term disability benefits in September 2006.
In July 2008, Prudential terminated his disability benefits, citing a lack of objective medical evidence to support his disability and resulting inability to perform his job. Upset and confused by Prudential’s denial of his disability benefits, he contacted Attorneys Dell & Schaefer to retain our services in the filing of his appeal. Review of the claim file by Attorneys Gregory Dell and Stephen Jessup revealed that Prudential was not properly classifying or recognizing the true nature of his pre-disability occupation with his employer. Therefore, Prudential was not reviewing his medical condition as it related to his ability to perform the duties of his occupation.
Dell and Schaefer attacked Prudential on this fact, submitting an initial appeal in January of 2009 that detailed the duties of his occupation and how, in light of these duties, his coronary artery disease prevented him from being physically unable to perform those duties. Prudential reviewed the initial appeal and within three weeks sent a second denial letter.
Review of Prudential’s second denial letter clearly indicated that Prudential did not even take into consideration the information submitted in the first appeal regarding our client’s occupation and again cited no medical evidence to support disability. A second appeal was filed in late July 2009, which once again illustrated how Prudential was improperly reviewing our client’s claim for benefits in violation of ERISA.
Attorneys Dell and Schaefer argued that although objective tests such as EKG’s indicated no abnormalities, the practice of medicine is not an exacting science, and that the only truth in our client’s medical history is that he repeatedly “passed” testing, and experienced a heart attack upon returning to work not once, but twice.
Following the submission of the second appeal, Prudential took the full 45 days to review his claim, and even requested an extension of an additional 45 days. During this period Prudential requested our client undergo an Independent Medical Examination, where once again diagnostic testing appeared normal, but his performance on other tests indicated the severity of his impairment.
Faced with the reality of our client’s medical history, and the fact they had improperly reviewed his claim for benefits, Prudential reversed their decision to terminate our client’s benefits and paid all past due disability benefits. Fortunately our client was able to prevail without the need to file a lawsuit.