Texas Court Upholds Prudential Disability Insurance Denial

Prudential paid total disability benefits for two years, but after certain communications from the claimant, his benefits were denied. Does doing dishes, laundry and cooking mean a person is ready to return to work 40 hours a week? Let’s examine the Texas case of Patterson v. Prudential Insurance Company of America, where the claimant unsuccessfully challenged an insurance company’s denial of long-term disability benefits.

The claimant fell down a flight of stairs at work in 2002, injuring both knees, both wrists, and his lower back. He underwent arthroscopic knee surgery and, as a result of the surgeries and injuries, received the maximum Short Term Disability benefits. Once the short-term benefits expired, the claimant could receive long-term disability benefits under the policy only if he were “totally disabled.” The plan’s definition of “total disability” required that the plaintiff be unable to perform the “material and substantial duties” of his occupation. After finding he was totally disabled, Prudential approved the claim for long-term disability benefits.

Prudential Denies Disability Benefits After Paying for Two Years

Two years later, Prudential reevaluated the plaintiff’s status as totally disabled. Prudential analyzed his medical history, which indicated that he had full motor strength in his upper extremities and that his range of motion was “limited but improving.” Prudential also reviewed a self-report submitted by the plaintiff that detailed his daily routine, which showed that he engaged in household activities like washing dishes, vacuuming and taking out the trash, as well as recreational activities like fishing, bowling and playing tennis. Based on the medical history and his self-reported activities, Prudential concluded that the plaintiff was no longer totally disabled and terminated his long-term disability benefits.

The claimant filed an ERISA lawsuit against Prudential and argued that his long-term disability benefits were wrongfully terminated because he was still totally disabled. Specifically, he said that he couldn’t perform certain duties of his job such as moving furniture, getting office supplies and lifting heavy files. Yet he acknowledged that most required tasks – like using a computer or answering the phone – were not physically demanding. The court found that Prudential could terminate the benefits because enough evidence existed to support the insurance company’s conclusion that he could perform certain tasks and, therefore, was not totally disabled within the meaning of the policy.

Patterson v. Prudential Ins. Co. of Am., 693 F. Supp. 2d 642 (S.D. Tex. 2010)

Leave a comment or ask us a question