Prudential terminates disability benefits of traumatic brain injury claimant in a case of mistaken identity

James H. White filed a lawsuit against Prudential Insurance of America in the United States District Court For The Eastern District of Pennsylvania for the insurer’s termination of White’s disability benefits after paying him disability benefits for twenty-four (24) months. Claiming that White’s disability was the product of a pre-existing metal illness, Prudential Insurance terminated White’s disability benefits because his policy with Prudential only allows 24 months of disability benefits when the disabling condition is related to a mental illness.

White sustained permanent brain injuries in a serious motor vehicle accident on April 21, 2007. His brain injury resulted in White having cognitive losses, which entitled him to long term disability benefits for sixty (60) months. At first, Prudential denied White his disability benefits, stating White did not qualify for benefits, only to later determine that White had indeed suffered a disabling brain injury, and subsequently, awarded White long term disability. So far, so good.

Medical Records Of Claimant Are Mixed Up With Those Of An Individual With The Same Name

A mix-up of medical records with another James White resulted in the James White of this lawsuit being denied his long term benefits because of the other James White’s mental condition. Mistakenly, Prudential terminated White’s disability benefits because the insurer had been provided with another James White’s medical records that documented a mental illness that predated April 21, 2007. The Plaintiff in the subject case not only has never suffered from a mental illness, but does not even slightly resemble physically or personality-wise the James White who does suffer from a mental illness. In fact, one of Prudential’s insurance reviewers noted this discrepancy to no avail.

On June 23, 2010, the plaintiff appealed the Prudential’s termination of his disability benefits and provided Prudential with statements from the facility and the office manager of the neurologist that mixed up the medical records of the two James Whites. In addition, the plaintiff submitted documentation from his physicians confirming that White’s disability from his job as Chief Financial Officer for Holt Oversight & Logistical Technologies was caused from a closed brain injury and not from an “alleged pre-existing mental illness.” According to White’s Prudential plan, he is entitled to $7,500.00 per month in disability benefit payments as long as he is disabled from performing his own employment.

White Retains The Services Of A Disability Attorney To Straighten Out The Mess

Mr. White retained Attorney John Leonard to file a lawsuit against Prudential. In his lawsuit, White and his disability attorney, accuse Prudential of terminating White’s disability benefits in an “arbitrary and capricious manner,” as Prudential will not acknowledge that it based its denial of benefits to White by relying on the wrong person’s medical records. White’s appeal has been pending for 11 months and Prudential has refused to allow White to see his file, a violation of its fiduciary duty to consider White’s appeal in a timely manner.

Background Of White’s Disability Benefits Lawsuit Against Prudential

On April 21, 2007, James White, his wife, their four children, and their nephew were involved in a high-speed car accident when their SUV was hit and consequently violently flipped several times, resulting in the SUV having a crushed roof, and with White and his wife losing consciousness. White was diagnosed with a closed head trauma and other injuries and his wife was diagnosed with a “life threatening and horrific head and neck injuries.” White’s long-term prognosis was a permanent brain injury from which he suffers “persistent headaches, dizziness, persistent ringing [of] the ears, personality changes, word finding deficiencies, loss of ability to multitask, loss of ability to remember, forgetfulness, mid temporal lobe brain damage, diminished profusion in the left occipital lobes of the brain, dementia and cognitive deficits.” White’s life has undergone profound changes as a result of his permanent brain injury, and he suffers anxiety, emotional distress and depression, which are characteristic of brain injuries such as his.

Though ill, White, while undergoing rehabilitation for his injuries and attempting to heal, was taking care of his almost totally immobile wife and attending to their children’s everyday needs. In August 2007, White’s symptoms worsened and in October of 2007, he sought treatment from his physician, who referred White to a neurologist for his closed head injuries and cognitive problems. After numerous tests, White’s neurologist determined that White indeed has a permanent brain injury that has rendered White totally disabled. White was also seen by a neuropsychologist who wrote a report dated March 14, 2008 confirming that White had “no prior history of anxiety, depression or treatment of any psychological disorder or disease” before the accident.

After exhausting his accumulated sick, personal leave, and vacation time, White applied for his long term disability benefits in September 2007. Prudential denied White his benefits, claiming that White wasn’t entitled to disability benefits because he delayed seeking treatment for his brain injury. White appealed Prudential’s decision and on July 25, 2008, was again denied long term disability benefits. Time after time, White appealed Prudential’s decision, each time providing more information and test results to no avail. Almost out of appeals, White had another insurance carrier review his claim; that reviewer determined that White is totally disabled and documented the review, which White enclosed in his last appeal to Prudential again to no avail.

After exhaustive tests, numerous physician records and documentation conclusively determining that White suffers from a permanent brain injury disability as well as the independent review, Prudential granted White his disability benefits retroactive to July 21, 2007. According to his Plan, White’s disability benefits had a limit of 24 months. Consequently, after the 24-month period, Prudential again terminated White’s disability benefits.

White Files A Lawsuit Against Prudential In An Attempt To Recover His Disability Benefits

According to his complaint White’s disability termination was “in contravention of the Plan provisions which state: ‘Prudential will not apply the mental illness limitation to dementia, if it is a result of:… trauma.” White’s neurologist confirmed that White’s mental condition was a result of the car accident and that White had never suffered from dementia previous to the accident in which he sustained a traumatic brain injury. In addition, Prudential still relied on the wrong person’s medical record, and “ignored, avoided or downplayed the violent nature of the accident,” White’s obvious health problems, and the opinions of his treating physicians in evaluating White’s disability benefits claim.

With a long list of ERISA violations and Prudential policy violations, White and his disability lawyer accuse Prudential of demonstrating “numerous substantive deficiencies and procedural irregularities which when coupled with its reliance on the wrong person’s medical record, its refusal to decide the pending appeal, its ignoring the opinion, records and tests performed by [White’s] treating physicians, and its refusal to provide Plaintiff with access to the contents of claims,” Prudential has breached its fiduciary duties toward White and should be penalized for doing so.

White Seeks Judgment On His Disability Claim Against Prudential

White and his disability lawyer ask the Court to grant an Order compelling Prudential to pay White the full amount o his disability benefits from September 1, 2009 until the present time and continue disability payments to White for the period “set forth in the Plan” along with pre judgment interest, reasonable attorney’s fees and any other relief the Court see fit and appropriate to settle this Complaint.

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