Team lead by Attorney Cesar Gavidia Forces Prudential to Overturn Long-term Disability Denial on Appeal for IT Support Technician Diagnosed with Cancer
Author: Attorney Cesar Gavidia
Jared was an IT Support Technician before small cell carcinoma in his middle ear caused fatigue, weakness, headaches, dizziness and head pains forcing him to submit a leave from work request and file a long-term disability claim with his employer’s LTD insurer, The Prudential Insurance Company of America (“Prudential”).
Clinical Specialist for Prudential Reviews Medical Records and Finds that Restrictions and Limitations Would Not Prevent Performance of Work Activities.
Aside from the significant emotional and physical issues that arise from a cancer diagnosis, the location of Jared’s cancer in his middle ear produced particularly impairing problems. Fatigue and weakness caused him to tire easily, headaches produced distracting pain causing him to lose focus, dizziness and head pains were equally distracting and made it impossible to focus on the information displayed on his multiple computer screens.
Prudential verified that Jared’s “Usual Occupation” was that of an IT Support Technician and that his job required installing and supporting desktop/laptop hardware and software, computers, office printers and maintaining personal computers. Prudential identified Jared’s usual occupation as being a “light occupation” requiring exerting up to 20 lbs. of force occasionally, and/or up to 10lbs. frequently, and/or a negligible amount of force constantly to lift, carry, push, pull or otherwise move objects.
Following submission of his long-term disability claim, Prudential found that Jared was indeed disabled from engaging in his usual occupation as an IT Support Technician and approved payment of his long-term disability benefit. After approving and paying Jared’s disability claim for approximately 10 months Prudential terminated Jared’s disability claim on the basis that its clinical consultant, whom it did not identify as a nurse or a physician, found that he did not have any ongoing limitations or restrictions from work activities.
Evidence Heavy Appeal Succeeds in Overturning Prudential’s Denial of Long-term Disability Benefits
The Appeal addressed a number of inconsistencies and inaccuracies in Prudential’s denial letter, starting with the fact that Prudential had approved Jared’s disability claim on the basis that his symptoms, which included dizziness, weakness, inability to carry a gallon of milk, inability to stand/walk for longer than 5 – 10 minutes, hearing loss in left ear, hand / leg numbness and difficulty swallowing, had not changed in the nine months since he had been approved. In addition, the Appeal addressed that Prudential had required Jared apply for social security disability benefits so that it could reduce his monthly long-term disability benefit payments, to only baselessly deny his claim after Social Security Disability promptly found a basis to approve him on his initial application. Attorney Gavidia and his team argued that Prudential failed to give the Social Security Disability approval any weight which violated ERISA.
The Appeal also included evidence and opinions from Jared’s treating physician which supported that he was unable to work in his usual occupation as an IT Support Technician. One particularly concerning piece of evidence included a statement from Jared’s treating physician disputing that Prudential had ever contacted him or even attempted to contact him, despite Prudential statement that it had attempted to contact his treating physician.
Within 3 weeks of submitting Jared’s Appeal Prudential notified Attorney Gavidia that it was overturning its decision, paying all back benefits owed and approving Jared for ongoing monthly benefits as long as he continues to meet the definition under the policy. Attorney Gavidia and his team continue to manage the proof of loss requests on a monthly basis and monitor Prudential’s handling of Jared’s claim.