• Prudential Disability Benefit Appeal Tips

Prudential Disability Appeal

Drafting a strong Prudential disability appeal following a benefit denial is like sitting down with a blank canvas and getting ready to do a painting. Every Prudential appeal our disability lawyers draft is unique because the disability policy language is unique to your claim, your medical condition and occupation are very specific, and the quality of the denial letter prepared by Prudential is a huge factor. Please watch our video above in which we discuss important tips for preparing a response to a Prudential disability denial. We have tons of information about Prudential disability claims that we think you will find helpful. Our clients are located in every state and we have handled hundreds of Prudential disability appeals. We never charge or clients any attorney fees or cost unless we are able to recover disability benefits and we welcome you to contact us for a free consultation.

Top 10 Reasons for a Prudential Disability Benefit Denial?

Plain and simple, Prudential is sloppy when it comes to their handling of short and long term disability insurance claims. The reason for their sloppy claim handling is that they have frequent employee turnover and at the initial claim review level it is common that an inexperienced disability claim rep is responsible for making the decision on your disability claim. Bigger is not always better and for Prudential they fail miserably at having skilled employees to properly review your claim. It seems as if every other Prudential disability insurance denial letter we review is similar and contains the following reasons for denial:

  1. The objective medical evidence does not support your subjective complaints of pain or functional limitation;
  2. Prudential had your medical records reviewed by their in-house nurse or doctor and determined that you do not have any restrictions and limitations that prevent work;
  3. Prudential sent your medical records to a third party medical review company and without examining you determined that you are able to work;
  4. Prudential determined that you have a medical condition with some functional limitations, but you can perform a sedentary job because you can lift up to 10 pounds and can sit in a chair for more than fours a day if given breaks;
  5. Prudential sent you for a compulsory medical exam and adopted the opinion of the hired gun doctor with complete disregard of the opinions of your treating doctors;
  6. Prudential hired a vocational consultant and determined that while you may be disabled from your own occupation there are other jobs in the national economy that you can perform;
  7. Prudential attempted to contact your treating doctor via phone or letter and after no reply in two days, Prudential ignores your treating doctors opinions about your restrictions;
  8. Prudential conducted video surveillance of you doing normal daily activities such as driving, going to a store, going to a restaurant and as such believes that you are not disabled;
  9. Your definition of disability changed from own occupation to any occupation and Prudential came up with a random job that they think you can do;
  10. Prudential determined that you have a mental condition and not a physical condition that is disabling; thereby limited the period of benefits you are eligible for.

How Does Your Law Firm Draft A Winning Prudential Disability Appeal?

The combination of multiple types of evidence are required in order to get your Prudential disability denial reversed. A great appeal requires a detailed review of your entire Prudential claim file, obtaining additional medical and vocational evidence in support of your claim, and strategic drafting of an Appeal letter that gives you the best chance to win without screwing up a potential lawsuit if your Appeal is not successful. The three types of evidence are:

Medical Evidence

Medical support is clearly the most important type of evidence that will be required if your disability claim has been denied based on a lack sufficient medical evidence to support your restrictions and limitations. The type of medical condition(s) that you believe are disabling and the number of doctors you are treating with will require a strategy to determine which doctor or doctors would be best to work with to obtain additional medical support. Our disability lawyers will work closely with you and your doctors to get the required additional medical support. We will advise you as the exact medical information that we believe will strengthen your claim. In the many of the appeals that we draft we often obtain additional medical support from a medical expert that you may not have seen before.

Medical support is clearly the most important type of evidence that will be required if your disability claim has been denied based on a lack sufficient medical evidence to support your restrictions and limitations. The type of medical condition(s) that you believe are disabling and the number of doctors you are treating with will require a strategy to determine which doctor or doctors would be best to work with to obtain additional medical support. Our disability lawyers will work closely with you and your doctors to get the required additional medical support. We will advise you as the exact medical information that we believe will strengthen your claim. In the many of the appeals that we draft we often obtain additional medical support from a medical expert that you may not have seen before.

  • Medical Records from your doctors/treatment providers
  • Psychotherapy Notes
  • Physical Therapy or Occupational Therapy Notes
  • Applicable diagnostic testing: MRI, Cat Scan, X-ray, bloodwork, EMG/Nerve Conduction studies and any other Objective Medical Testing
  • Specialized testing such a neuropsychological testing or functional capacity examinations that can help verify subjective complaints
  • Attending Physician's Statements
  • Behavioral Health Statements

This is by no means an exhaustive list of medical based information to be submitted with an appeal. Within each of the above referenced items it is incredibly important that the content of these documents accurately reflect your condition and its impact on your ability to work. This may seem like an obvious statement, but all too often we see medical records and claim forms that contain errors (often due to standardized data entry forms in common medical record keeping systems) or that omit a patient's complaints as to how their medical condition impacts their ability to work, or fails to establish medically supported restrictions and limitations- a standard that all insurance companies will look for in determining whether or not you should be paid. It is not enough to simply have a large quantity of supportive medical information, it must be quality information that properly documents the medical condition and establishes a connection between the condition and how it impacts your ability to work in either your occupation or any gainful occupation.

Occupational Evidence

The occupational evidence presented in a disability appeal must be presented based upon the applicable definition of "disability" in your Prudential disability policy. A common phrase in the disability insurance industry is "Diagnosis does not equal disability." Meaning, simply having the diagnosis of a medical condition is not enough for your claim to be approved. There has to be a nexus drawn between the diagnosis and how it results in an inability to work. Complicating this further is the fact that Prudential policies will have two definitions of disability- the inability to perform the duties of your own (or regular occupation) and the inability to perform the duties of any occupation based on your training, education and experience. Each of these distinct periods in your claim requires different analysis in order to get your claim approved. When submitting an Appeal we always provide in depth vocational information regarding your occupation. Our presentation goes way beyond your formal job description, as we conduct industry specific research, have you undergo functional capacity testing specific to your occupation if applicable, work with rehabilitation consulting experts to generate vocational reports, provide samples of your work when necessary, obtain statements from co-workers and supervisors, and have labor market analysis completed to analyze availability of work that Prudential thinks you can perform.

How does Prudential determine what the duties of your own occupation were, or what the duties are of an alternate "any" occupation? Prudential policies contain language that defines an occupation to mean how the job is typically performed in the national economy, and not how it is performed for your specific employer or specific location. It is known commonly as the "national economy" standard. Additionally, despite the fact many people work in excess of 40 hours a week, Prudential only has to determine the ability to work based on a 40 hour week regardless of how many hours you may work. In the any occupation definition of disability Prudential's policy will usually define gainful occupation as a job that will pay you at least 60% of what you earned pre-disability.

In any denial of benefits, Prudential will conduct some type of vocational review that will establish what your occupational duties are based on the national economy standard or if your claim is in the "any occupation" stage, what the applicable alternate occupations are that you can perform based on your education, training and experience. This is why Prudential will send claim forms during the claims process that inquire about your work history, education, volunteer work, vocational training, etc. They are building up a reserve of information to be used against you later in the transition between the own occupation and any occupation standard of disability.

Often the vocational reviews performed are nothing more than a review and conglomeration of the descriptions for an occupation as contained in the Department of Labor Dictionary of Occupational Titles, O*Net, or some similar industry recognized vocational reference tool. The vocational expert for Prudential will not review your medical records to determine your ability to perform the noted duties, but will rather rely on the reports conducted by Prudential's in-house doctors and nurses, outside medical reviewers, or independent medical examiners to determine what your physical restrictions and limitations are.

Why Does Prudential Ignore Your Actual Job Duties?

Although Prudential will typically define disability to mean the inability to perform the material and substantial duties of one's regular (own) occupation; or the inability to perform the duties of any (gainful) occupation based upon training, education and experience, quite often when someone receives a denial letter Prudential does not appear to have even considered your actual occupational duties. Instead, Prudential will often state that your occupation was "sedentary" (or whatever the physical demand level is) and that in their opinion the information suggests you can perform at a sedentary demand level and as such the claim is denied.

The Physical Demand Level (PDL) of an occupation is the physical requirements of an occupation as set forth by the Department of Labor. The various levels are sedentary, light, medium, heavy and very heavy. Prudential's determination of occupational requirements as being nothing more than the ability to perform at the PDL that one's job is customarily performed at is inherently wrong in that it creates a standard of disability that is not found in the policy. For example, my occupation is a Lawyer, which falls into the sedentary demand level according to the Department of Labor. That being said, I do not make a living because of my ability to lift up to ten pounds, rather my job requires an extensive list of cognitive skills. By Prudential's logic I would then be able to perform the duties of my occupation solely because I can perform at a Sedentary level. This is certainly absurd, but I can assure you it happens day in and day out to people whose claims have been denied.

Character Evidence

The person employed by Prudential has never met you before and likely never will. This a problem because Prudential only knows you based upon the information that is written in your medical records. Character evidence gives you the opportunity to let Prudential know who you really are and how your medical conditions limits you. Additionally, if Prudential denies your appeal, ERISA laws do not give you the opportunity to be heard by a judge or present any additional evidence following a final appeal denial. We submit character evidence with the potential that not every appeal will be won and we want the Judge to be able to consider evidence which Prudential may ignore. With the submission of your appeal we will work with you to draft a personal statement that explains how your medical condition(s) prevent you from being able to work. We may also obtain statements from friends, co-workers, supervisors, and family members if we believe that it will be helpful. If you have a social media profile it will always be a factor in a disability claim, so it must be reviewed and explained if necessary. In some disability appeals we have submitted video statements or recorded statements so that the disability carrier has the opportunity to actually hear why you cannot work. We also use the character evidence to support the validity of your complaints

Clear Presentation of Either Your Occupational Duties or Any Occupation Must be Presented in Your Unum Appeal

Your treating doctors must have a clear understanding of your occupational duties pre-disability and the duties required for you to perform any occupation that you may be qualified to perform. We have represented claimants in every occupation and have developed a very practical approach for how we present the duties of either your occupation or any occupation to your doctors. In a high percentage of disability claims the claimant must be unable to do a sedentary desk job in order to be disabled and our job is to get your doctors to properly document why you cannot do a sedentary job. Unum wrongfully thinks that if you can sit a desk for more than four hours a day, then you are capable of working. Any job requires far more than the ability to just sit in a chair for more than four hours. Unum's method for analyzing a sedentary occupation is outrageous as no one's job description says "must be able sit for four hours a day and nothing else required". In disability policies that have an own occupation definition of disability we conduct our own occupation specific industry research and work closely with you and your past co-workers to present extensive documentation in support of your occupational duties.

The Manner in Which a Final Unum Appeal is Written Must Be Strategic

This paragraph may contain more legal information than your care to know so I will try to make it as simple as possible. We also have a video below discussing the importance of a strategically drafted ERISA appeal and you can also call us for further clarification and help with your appeal. There is only one chance to submit a Unum appeal and it must be drafted in a manner so as to not tell Unum everything they did wrong. Most people, including lawyers that don't focus their legal practice on Unum appeals will submit appeals where they basically give Unum a roadmap on how to review the appeal by telling Unum everything they did wrong on the initial review. They will include lots of case law and a detailed criticism of everything Unum did wrong. This is not a helpful strategy and really does nothing more than guide Unum as to how to conduct a reasonable review of your initial claim denial.

The "reasonable review" language is key because if your appeal is denied by Unum and an ERISA lawsuit is filed, a judge must review the denial and apply an unfair legal standard called "abuse of discretion". The abuse of discretion standard requires a judge to first determine if the claimant is disabled and then if the judge thinks the claimant is disabled, the Judge can only reverse the claim denial if he or she thinks the review conducted by Unum was unreasonable. So a Judge can find that a claimant was disabled, but Unum's review of the claim with a conclusion of not disabled was reasonable. In this scenario the claimant loses the case as the Judge must defer to the reasonable review conducted by the insurance company. Because of the abuse of discretion standard that applies to any Unum disability policy that contains a "discretionary clause", we always draft a strategic appeal that focuses on your medical restrictions/limitations and how you are disabled in accordance with your disability policy's definition of disability. There are a few states where the discretionary clause is illegal and the judge's decision on the claim will be final regardless of the reasonableness of Unum's appeal review.

Regardless of the standard of review that will apply to your Unum disability appeal denial, our have a very specific style of organizing, preparing and drafting Unum appeals letters which has helped thousands of disability claimants nationwide to receive their disability insurance benefits.

We hope you find all of the additional information we have on website about Unum helpful and we look forward to discussing your Unum disability appeal with you.

  • Prudential denied the claim based on objective medical evidence
  • Prudential's in-house doctor denied the disability claim
  • With no exam a third party medical company denied a Prudential claim
  • With functional limitations Prudential denied a disability claim because claimant has the ability to perform sedentary occupation
  • After a compulsory medical exam a doctor hired by Prudential denied the disability claim
  • Prudential denied claim based on a vocational consultant evaluation of employable with other occupation
  • Prudential ignored claimants treating doctor's opinion of limited work restrictions and denied claim
  • Based on video surveillance Prudential denied disability claim
  • My definition of disability changed from own occupation to any occupation and Prudential denied my disability claim
  • Prudential based your denial on a mental disability and not a physical disability

Answers to Your Prudential Disability Questions

When Does Prudential Usually Deny Disability Benefits?

Chances are if you have received a denial from Prudential it has come without warning. Typically it starts with not receiving your monthly disability benefit on time. When inquiry is made it is not uncommon that you are unable to reach your claims manager to find out what is going on. It may be some time after your monthly benefit doesn't arrive that you receive a letter in the mail dated prior to the date your check was to be issued advising you that your claim has been denied. The courtesy of a phone call or advance warning of the denial is not common for most people who have been denied by Prudential.

In our experience representing insureds against Prudential a person's disability claim is most likely to be denied by Prudential at one of two junctures: (1) the long term disability application stage and/or the transition period from short to long term disability and (2) at the transition from the "own occupation" to "any occupation" definition of disability. The point at which the claim is denied or terminated will often dictate how one must draft their appeal to ensure continued benefits. That being said, all disability appeals are always drafted in the context of ERISA as a body of law, which is unfortunately quite unfair for the insured. We have written and discussed numerous times throughout our website and videos as to how ERISA is an unfair body of law and having a policy governed by ERISA greatly impacts claims for disability benefits so we will not belabor the point here.

If Prudential has denied all of my disability appeals can I submit new information?

The answer is no. The biggest take away and cautionary warning when submitting an appeal to Prudential is the fact that in the event of a final denial of benefits (all appeal levels are denied) no new information can be brought into your file for a Court to consider. This means that any information that supports your claim for disability must be introduced during the appeal process. Failure to properly supplement your file could make it next to impossible to prevail in Court. Your appeal is your final shot to secure your benefits.

It is common for an insured who just found out their benefit was denied/terminated to be told by the claims manager that all they have to do to file an appeal is write a letter stating they disagree with the denial of benefits. Although this is not technically a lie, as an appeal is essentially a disagreement with Prudential's claim denial, it is certainly not the complete truth. Your appeal is your opportunity to systematically attack Prudential's denial of your claim. If you fail to strategically plan your attack you could be left at the mercy of a body of law that as a default favors the insurance industry. Consulting with an attorney to discuss your rights is highly recommended given that an appeal done without a disability lawyer could lacking significant evidence.

Is Prudential's Voluntary Second Disability Appeal Good or Bad for claimants?

The quality of the initial appeal denial drafted by Prudential and the strength of the documentation submitted during your appeal will determine if a second Prudential appeal should be submitted. Under ERISA, an insured is required to file at least one mandatory appeal of a denial of benefits before a civil lawsuit under ERISA can be brought. Whereas some insurance companies have two mandatory levels of appeal, Prudential falls in line with the ERISA minimum standard of one mandatory level of appeal. However, unlike most insurance companies, Prudential does allow for a voluntary level of appeal. Although having a second level of appeal is a positive in that you will have two chances to appeal the denial of benefits, the rules governing the voluntary second level of appeal are much less favorable than those in place during the mandatory level of appeal.

So what is the difference between a mandatory and a voluntary appeal? Under ERISA during the mandatory appeal level Prudential is required to have your entire file reviewed by doctors/medical professionals and claims people who had no part in the initial review and denial of your claim. Basically- you have a fresh set of eyes reviewing your entire file to see if the initial decision to deny/terminate benefits was correct. The mandatory appeal is the most impartial review you will have. However, on a voluntary appeal Prudential is not required to have your file reviewed by a new set of doctors/medical professionals or claim manager. In the event that your claim is denied on the first appeal Prudential can send your second voluntary appeal back to the same doctors/medical professionals who just reviewed and denied your appeal. Needless to say, convincing a doctor who likely has never met you that their opinion is incorrect is no easy task. For all intents and purposes, your mandatory first appeal is the only true independent review you will get, and as such it is crucial that your appeal is as ironclad as possible.

How long will it take for Prudential to make a decision on my appeal?

Under ERISA, Prudential will be allotted an initial 45 days to respond to your appeal, with the ability to request a 45 day extension prior to the expiration of the initial 45 days. The extension is supposed to be based on a showing of good cause as to why the extension is necessary, but from our experience most requests for extensions are based more on a lack of efficiency than need. It should also be noted that the 45 day timeframe can be "tolled" for multiple reasons, such as if you submit additional information after the appeal is submitted, Prudential is waiting for a response from your doctor or is waiting for you as the insured to provide requested information. Prudential will try to delay the process as long as possible, so it is important your combat the possibility of this happening. This is why we harp so strongly on making sure you have all supportive information for your appeal ready for submission at the time the appeal is filed.

Questions About Hiring Us

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

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Daniel M., M.D.

The team at Dell & Schaefer was able to guide me through the confusing disability claim process efficiently while explaining every step along the way. They provided me with peace of mind during a very stressful period of my life. Dell & Schaefer was not only there for me during the claims process but also after ready and willing to answer any question I had.

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