Our client was unable to work long term due to long-term disability and long-term leave in 2020. She appealed her long-term disability benefit and won $107,000 for the long term benefits she should have been paid during that time.
Our client was unable to work due to long-term disability and long-term leave in 2020. She won her short-term disability benefits for the entire 6 month period that she was entitled to. She applied for long-term disability benefits and she was denied.
The Appeal Process
Firstly, our client appealed her long-term disability benefit. We are happy to tell you that our client’s long-term disability appeal has won her $107,000 in long term benefits she should have rightfully received after her elimination period beginning January of 2021 and continuing.
This ERISA disability appeal involved many conditions which caused our client’s inability to work – including chronic degenerative disc disease, chronic knee pain, diabetes, depression, and anxiety.
Our long-term disability appeal letter was 55 pages long. This long-term disability appeal was especially difficult for our client because her combination of illnesses not only kept her from working but also prevented her from doing most things she used to do, including housework & caring for herself/her family.
She tried to work and go back to work in 2020 but could not physically or mentally do it anymore. A lot of long term mental anguish stems from the inability to physical do the things she used to be able to do.
The Denial
Part of the appeal included significant criticism of Prudential Insurance Company’s review process. Of course, she was clearly disabled during her short term disability benefit. Somehow, according to Prudential, during that six months, her chronic conditions somehow improved to the point she could return to work (read that with a sarcastic tone).
Additionally, Prudential’s denial letter was a mere copy and paste job where the claims specialist took a nurses opinion and just changed the pronouns. This is unacceptable. There was no “deliberate, principled reasoning process” that we can determine based on either reading the denial letter or reviewing the complete claim file. There appears to have been no review at all!
Moreover, the law is simple: A plan administrator must begin the disability determination “with a precise and detailed listing of the essential duties of” the claimant’s job. Ransom v. Unum Life Ins. Co. of Am., 250 F. Supp. 2d 649, 656 (E.D. Va. 2003). “Let us be perfectly clear: under an own occupation standard, medical evidence is only part of the equation. To assess a claimant’s ability to perform his own occupation, a decision maker must be aware of, and apply, the requirements of the occupation.” McDonough v. Aetna Life Ins. Co., 783 F.3d 374, 381 (1st Cir. 2015).
And, no one bothered to consider what our client’s job description was.
Indeed, at least one Virginia federal district court has held that “[b]y failing to adequately consider [the claimant’s] job description and other evidence of Material and Substantial duties of his job, [the insurance company] did not engage in the ‘deliberate, principled reasoning process’ that was required of it.” Sapp v. Liberty Life Assurance Co. of Boston, 210 F. Supp. 3d 846, 852 (E.D. Va. 2016).
Lastly, Prudential wrote to our client’s doctors and asked for their opinions. But, in writing that letter, the nurse told the doctors that the Prudential agreed she was disabled. So, of course, neither doctor responded. Prudential used that as evidence that our client did not have a disability and that her doctors did not support her disability.
Look, treating physicians are busy and highly practical people. We get it. But, if Prudential’s letter said, “yeah, we think your patient is disabled, but tell us if you disagree,” of course the doctor won’t respond. The doctor didn’t disagree!
“The duty to disclose material information is the core of a fiduciary’s responsibility, animating the common law of trusts long before the enactment of ERISA.” Kenseth v. Dean Health Plan, Inc., 610 F.3d 452, 466 (7th Cir. 2010) (quoting Eddy v. Colonial Life Ins. Co, 919 F. 2 d 747, 750 (D.C. Cir. 1990)). “This duty exists when a beneficiary asks fiduciaries for information, and even when he or she does not.” Id.
This, known as the duty to engage in a meaningful dialogue, did not do its job. But Prudential’s dialogue was anything but meaningful. Hence, the 55-page appeal letter!
These long-term disability benefits were long overdue and we are happy to be able to tell you our client has received long term disability benefits she should have rightfully been paid since January of 2021.
What to Do If Denied Benefits
If you’ve been denied short-term or long-term disability benefits, give us a call or send us an email. We’d love to talk to you about winning your appeal!
Of course, every case is different and depends on the unique circumstances presented. So we cannot make any guarantees that the result you read about here is the same result that we will be able to accomplish for you in your case. The only guarantees we can make are that we will be honest with you about your case, and that we will will give 100% effort to win.
