Because of his multi-level degenerative disc disease and severe spondylosis, our client was unable to continue working as regional sales representative for a national food service company. He applied for his long-term disability insurance benefits promised by Prudential. When Prudential denied his initial claims, he sought out Grabhorn Law to assist him with his appeal.
Grabhorn Law, working with our client and his treating doctors, prepared an appeal with additional supporting evidence as well as a discussion of the errors with Prudential’s denial decision. Prudential agreed with Grabhorn Law’s appeal, agreed our client was disabled from performing his full-time duties as a regional sales representative, and agreed to pay his monthly long-term disability insurance benefits for the balance of his own occupation period – two years.
Prudential further agreed to review whether he was also eligible to receive ongoing monthly long-term disability insurance benefits based on a change in the policy definition. After two years, the definition changed from protecting his prior occupation (own occupation) to any occupation. Unfortunately, when it completed its review of his any occupation long-term disability insurance benefits, Prudential denied his claim.
Another appeal was prepared and filed by Grabhorn Law, but Prudential denied the appeal based on the opinions of its own paid medical record reviewers. Prudential disregarded his treating doctor’s opinions, his favorable Social Security disability (SSDI) decision, and his supporting Functional Capacity Evaluation (FCE).
Grabhorn Law then prepared and filed an ERISA lawsuit on our client’s behalf to recover his long-term disability insurance benefits, and informed the Court of the numerous errors in Prudential’s denial. The Court held that “Prudential, without explanation, rejected the opinions of two medical providers who had examined [our client] … Instead, it relied primarily on the conclusions of …a file reviewer… Prudential also rejected the disability determination of the Social Security Administrative Law Judge without any substantive discussion of why it did so. Moreover, Prudential relied solely on a file review when assessing symptoms that were largely subjective and therefore necessarily required a credibility determination.” Therefore, the Court ruled in our client’s favor and ordered Prudential to re-evaluate our client’s claim for ongoing long-term disability insurance benefits.
Following the Court’s order, the parties participated in a joint mediation and reached a confidential settlement to the satisfaction of our client.