Prudential reverses denial on second appeal & pays $175,000 in past due disability benefits to OBGYN
Author: Attorney Gregory Dell
Medical Condition and Occupational Duties
Our Client, an OBGYN (hereinafter referred to as “Dr. OBGYN”), was employed by a hospital when he began to experience anxiety and depression following the filing of a malpractice lawsuit. Our client began drinking alcohol on a daily basis and was subsequently hospitalized for three months as a result of alcoholism, anxiety, depression and suicidal thoughts. Prior to claiming disability Dr. OBGYN’s substantial and material duties involved the delivery of babies, gynecological surgeries and on-call requirements.
Our Client’s disability plan was provided as an employee benefit from his employer, which meant that his disability plan was governed by ERISA. As a result of having a disability plan governed by ERISA, our client was required to exhaust his administrative remedies and file two written appeals with Prudential before he could he file a lawsuit. Attorneys Dell & Schaefer was retained on this case following Dr. OBGYN’s initial denial of benefits by Prudential.
In Prudential’s initial denial letter they claimed that Dr. OBGYN was disabled during the three month period of time that he was hospitalized, but that he was capable of returning to work immediately following his hospital discharge. Prudential’s opinions were reached based upon a paper review of Dr. OBGYN’s medical records by a doctor employed by Prudential doctor. Prudential denied the first appeal on the basis that Dr. OBGYN was only disabled when he was drinking and therefore he should be capable of working. Prudential completely ignored the fact that a substance abuse disorder is a disabling condition. Prudential never examined Dr. OBGYN in order to evaluate his medical condition.
Through a coordinated effort between our law firm and Dr. OBGYN’s treating doctors, we were able to present Prudential with additional medical information in support of the claim for long-term disability benefits. The additional medical information and our extensive second appeal letter were submitted to Prudential in a timely manner. Within 45 days of receiving the second appeal letter, Prudential reversed their previous two denials and determined that Dr. OBGYN was eligible for disability benefits. Since Dr. OBGYN suffered from a mental nervous and substance abuse disorder, the disability policy limited him to two years of disability benefits. Dr. OBGYN was awarded more than $175,000 in past due disability benefits.
This Prudential ERISA appeal was handled by Attorney Gregory Dell.