Wednesday, June 16, 2010

Prudential Approved LTD, For Now

I represent a 37 year old woman from Wisconsin with back and neck impairments who worked as a territory manager for a food distribution company until October 2007. Prudential initially determined that the claimant was unable to resume working at her own job and approved benefits under a group long term disability (“LTD”) policy based on the opinions of the treating specialists. Subsequently, Prudential terminated the LTD benefits based upon the conclusions of three “independent” doctors from MES Solutions who never examined the claimant.

On appeal, I showed that the conclusions of the MES doctors could not be sustained. First, I obtained narrative reports and functional assessments from the treating doctors rebutting the MES doctors’ reviews. Second, I sent the claimant for a functional capacity evaluation that yielded test results consistent with the opinions of the treating physicians. Third, I also sent the claimant for an independent medical exam, which also corroborated the findings and conclusions of the treating physicians.

Because I had anticipated that Prudential would conduct a protracted review, I advised the claimant to ensure that her doctors specified that not only was she incapable of performing her regular occupation, but also that they address her inability to perform even less strenuous sedentary work on a sustained basis. After 24 months of receiving LTD benefits, the claimant’s group LTD policy redefined disability from being unable to do past work, to being unable to do any work.

It took a year and four months to get Prudential to reverse its termination of benefits. Today I received Prudential’s letter approving benefits for “a minimum of 24 months of benefits,” which leaves the claim for LTD benefits after April 8, 2010 unresolved. In other words, just as I had warned the claimant, once she forced Prudential to concede that she would be unable to return to her job, Prudential would then turn to its fall back position and contend that her ability to perform any other work had yet to be established.

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