Prudential Insurance Wrongful Denial of Disability Insurance Claim

The Prudential Insurance Company of America ("Prudential") is a very large insurance company that is a frequent administrator of long-term disability benefits.  Whenever a person has their disability insurance through work, it is usually governed under the federal law known as ERISA.  Prudential is frequently the insurance company providing disability insurance benefits.  If your claim for disability insurance benefits is denied, then you should consult with an ERISA disability attorney.  Evan T. Engler is an ERISA disability attorney helping clients across Ohio and the 6th Circuit states of MIchigan, Kentucky, and Tennessee.

Prudential's Definition of "Disability" Changes Over Time

Prudential usually has a definition of "disability" that changes after 24 months of insurance coverage.  Every disability insurance plan could be slighly different, but in general, Prudential will consider a claimant to be "disabled" within the first 24 months of the claim if the claimant is unable to work at their current job.  After 24 months, the definition of "disability" changes so that a claimant is only considered "disabled" if they are unable to work at any job.  This has the effect of making it very hard to stay on disability insurance after 24 months.  That definition change is usually when insurance companies kick individuals off of disability insurance.

In Adams v. Prudential Ins. Co of America, 280 F.Supp.2d 731 (N.D. Ohio 2003), Prudential informed the disability insurance claimant that after 24 months they no longer met the definition of disability.  The claimant said that he couldn't work due to chronic pain, dependence on narcotic pain medication, and its impact on his ability to get to work.  Prudential performed an employability assessment that identified 5 types of jobs that the claimant was allegedly qualified for and could perform.  The claimant did multiple administrative appeals and was denied by Prudential each time.

The insurance claimant said they were unable to work largely because they couldn't drive.  As part of their treatment plan they were prescribed a number of narcotic pain killers and the claimant was not able to operate heavy machinery on those pain killers.  The Court ultimately agreed that the claimant's reliance on narcotic pain medications like oxycontin, zoloft, neurontin, and demerol could impair their ability to drive.  The Court found that Prudential never properly evaluated the effect of the claimant's medications on their ability to drive to and from work.  If they couldn't drive to work, then they couldn't work.  The Court granted disability benefits to the claimant and awarded the claimant attorney fees plus their back owed benefits.  

Wrongful Denial of Benefits After Definition Change

Prudential and just about every other disability insurance company have different definitions of what it means to be "disabled" that change over time.  It is usually easier to get on disability benefits in the beginning, but then when the defintion of "disability" changes to where the claimant cannot work at any job, then that is usually when the insurance companies kick the individuals off of disability benefits.  If your disability benefits have been denied after a definition change or otherwise then you should consult with an experienced ERISA disability insurance attorney.  You can call Evan T. Engler today at (614) 610-9988.

Life Insurance Company of North America Disability Insurance Denials

Life Insurance Company of North America, a subsidiary of CIGNA, is one of the largest disability insurance companies in the United States.  Attorney Evan T. Engler has helped a number of clients seek justice for their wrongfully denied disability insurance benefits by Life Insurance Company of North America or CIGNA.  If your claim for disability insurance benefits has been denied by the Life Insurance Company of North America then you should contact attorney Evan T. Engler at (614) 610-9988.  Evan T. Engler is an attorney and partner at the Columbus, Ohio based law firm of Harris & Engler and he helps clients with federal ERISA claims all over the Sixth Circuit states of Ohio, Michigan, Kentucky, and Tennessee.

File Only Reviews by Insurance Company Physicians

Because Life Insurance Company of North America is such a large disability insurance company, a number of ERISA lawsuits have been filed against them in federal district court.  In Calhoun v. Life Ins. Co. of N. Am. (6th Cir. 2016), the disability insurance claimant was a senior maintenance technician who had chronic leg and back pain to the point to where he couldn't sit or stand for periods of over 20 minutes or so at a time.  Life Insurance Company of North America ("LINA") initially approved the claim for disability insurance benefits, but then denied the disability insurance benefits after hiring a surveillance company which found the claimant grocery shopping and carrying grocery bags, among other reasons.  The denial was appealed by the claimant and supported by medical records documenting the injury.  LINA sent the whole medical file for review to different physicians for a "file only review," meaning that the physicians would only review the claimant's medical records and make an opinion on disability from those.  The 6th Circuit found that file only reviews where the reviewing physicians raise concerns about the claimants credibility in claiming pain, without ever physically examining the claimant is a problem.  In Calhoun, LINA's file only review physicians reviewed medical records and functional capacity evaluation results describing the claimant's disability and his limitations and then the physicians, without any real explanation, said that the claimant could work 40 hours per week.  The 6th Circuit found the LINA's decision to deny the disability benefits was arbitrary and capricious because LINA had an opportunity to have their own physicians personally examine the claimant, but they did not do that, instead they just had the physicians review the claimant's file in making their decision to deny benefits.  

This is similar to what happened in Guest-Marcotte v. Life Ins. Co. of N. Am. (6th Cir., 2018).  There the claimant sufferent from a disease characterized by chronic pain and fatigue and LINA denied the claim without exercising their right to have the claimant physically examined by doctors.  The court found that "the failure to conduct a physical examination, where the Plan document gave the plan administrator the right to do so, raises questions about the thoroughness and accuracy of the benefits determination."  In Guest-Marcotte, LINA discounted the claimant's claims of disabling pain, essentially labeling them as "subjective."  The file-only reviewing physicians hired by LINA found that there was no objective medical evidence supporting the limiting effect the pain had on the claimant's ability to work.  The court found in favor of the claimant because it was undisputed that she had a hereditary disease known to cause chronic and severe pain, and she submitted a host of evidence indicating that she in fact suffered from such pain.  LINA had the ability to physically examine the claimant, but instead took the word of file-only review physicians over the claimant's own doctors who actually saw her in person.  

These kind of disability insurance claim denials happen all too often, but there is something you can do about it.  You can hire an ERISA disability attorney to fight for your rights in getting your disability insurance benefits back.  Attorney Evan T. Engler works with clients for ERISA cases in Ohio, Michigan, Kentucky, and Tennessee to seek justice against disability insurance companies who have wrongfully denied claims for disability insurance benefits.  You can call Evan T. Engler today by calling (614) 610-9988.

Disability Insurance Companies Denying Disability Insurance Benefits When Social Security Disability Was Approved

The United States Supreme Court ruled that insurance companies have a conflict of interest when they decide disability insurance claims that they themselves pay out.  In the case of Metro. Life Ins. Co. v. Glenn, 128 S.Ct. 2343, 554 U.S. 105 (2008), the Supreme Court found that there is a conflict of interest when an insurance company both decides whether or not to accept or deny a claim for disability benefits and also be the entity to either pay those benefits or save money by not paying those benefits.  

Most disability insurance plans have a requirement that if someone gets their claim for disability insurance coverage approved then that individual must also apply for Social Security Disability benefits.  Usually the insurance company itself pays for a law firm or company like Allsup to represent the individual in applying for Social Security Disability benefits.  Then if that individual gets accepted for Social Security Disability benefits, then the disability insurance company is entitled to set off whatever the individual receives from Social Security from the amount they have to pay in disability insurance benefits.  For example, if an individual is receiving $2,000 per month in disability insurance benefits and then they get approved for $1,500 per month in Social Security Disability benefits, then the disability insurance company gets to set off the SSDI benefits and only pay $500 per month.  

In Metro. Life Ins. Co. v. Glenn, the individual got approved by Metlife for long term disability benefits.  But then Metlife required the individual to apply for Social Security Disability benefits.  The individual was found to be permanently disabled and approved for Social Security Disability benefits.  Then when the disability insurance plan changed the definition of "disabled" after 24 months from 'unable to work at the employee's former job' to 'unable to work at any job,' Metlife denied the individual saying they could do sedentary work.  The Court found that the disability insurance company had a conflict of interest because they both decided when to accept or deny the claim for disability insurance benefits and they pay out those disability insurance benefits or save money by not paying them out.  The Court found that Metlife never properly reconciled their own conclusion that the individual could work other jobs with the Social Security Administration's conclusion that the individual couldn't work any other job.

When an individual is approved for SSDI and denied by their disability insurance company, the Court will look with a more scrutinizing eye at the insurance company's decision to deny disability insurance benefits.  

If your disability insurance benefits have been denied you should contact an ERISA disability insurance attorney.  Attorney Evan T. Engler is an ERISA disability lawyer and partner at the Columbus, Ohio based law firm of Harris & Engler.  Attorney Evan T. Engler helps individuals who have had their disability insurance benefits denied in Ohio, or the other Sixth Circuit states of Michigan, Kentucky, and Tennessee.

ERISA Disability Attorneys

"ERISA disability" means when you have private disability insurance through your employer.  ERISA is a federal law called the Employee Retirement Income Security Act of 1974.  You need an ERISA disability attorney when your application for disability insurance benefits has been denied or when you have been receiving disability insurance benefits but the insurance company has decided to stop paying your benefits for one reason or other.

Why Do You Need An Attorney For Denied Disability Claims?

The federal ERISA statute provides a specific set of guidelines and requirements that have to be met by insurance companies who are administering or deciding to deny your disability claim.  These requirements can make it hard for individuals to get their disability insurance benefits reinstated.  That is why if your disability claim gets denied, you need the experienced guiding hand of an ERISA disability attorney to guide you step-by-step through the process of trying to get your disabillity benefits back.

What Does An ERISA Disability Attorney Do?

An ERISA disability attorney knows the specific steps and procedures that must be done to give you the best chance to get your disability insurance benefits back.  Attorney Evan T. Engler is an ERISA disability attorney and partner at Harris & Engler.  Evan T. Engler has vast experience helping disability claimants appeal the denial of their disability insurance or otherwise getting payment for their denied disability benefits.  Attorney Evan T. Engler has been successful at every stage of getting his clients compensation for their disability claims, whether through appeals with the insurance companies themselves or by filing federal lawsuits against the insurance companies that wrongfully deny disability insurance benefits.

For ERISA disability cases, attorney Evan T Engler does not charge any attorney fees unless you get payment for your previously denied disability benefits.  If you don't get payment for your disability case, then you don't pay any attorney fees.  Evan T. Engler is a partner at the Columbus, Ohio based law firm of Harris & Engler and he helps clients whose disability claims have been denied across Ohio, Michigan, Kentucky, and Tennessee.  You can reach ERISA disability attorney Evan T. Engler by calling (614) 610-9988.  

ERISA Disability Insurers Frequently Try to Deny Claims Because of Alleged "Pre-Existing Conditions"

It happens all too often - an individual is unable to work because of a disabling condition, they fill out a disbility claim form, provide supporting medical documentation, and wait for the decision of the disability insurance company.  Then when the decision letter from the disability insurance company finally comes, the insurance company denies the claim because they say the claimed disability was actually caused by a pre-existing condition that was either before employment started or before the effective date of the policy.  There are only two choices for an individual in this situation: (1) give up and do nothing; or (2) appeal the decision to deny the disability claim.  If it is option number 2, then the individual should get a disability insurance attorney to handle the appeal.  If the cost of an attorney is a concern, then it shouldn't be.  The ERISA attorneys at Harris & Engler only collect a fee if you win your appeal or lawsuit.  If you don't win, you don't pay anything.  An individuals chances of success in appealing a denial decision is exponentially greater by hiring an attorney experienced in ERISA disability insurance denials.

Examples of Disability Insurance Denials for Pre-Existing Conditions in the Sixth Circuit and in Ohio

Having diabetes is a somewhat common reason for disability insurance companies to deny a later occurring more serious injury.  In the Sixth Circuit case of Collins v. Unum Life Insurance Company of America (2017), an individual had diabetes and one day tripped in his employers parking lot.  He fell and broke an ankle.  His foot later had to be amputated.  Unum Life Insurance Company denied his claim for long term disability coverage because they said it was his history of poorly maintained diabetes that was the reason his foot had to be amputated.

Unum denied coverage due to their disability insurance policy provision excluding from coverage any "accidental losses caused by, contributed to by, or resulting from ... disease of the body."

That case was similar to an Ohio disability case in Morgan v. United Omaha Life Insurance Company (S.D. Ohio, Mar. 11, 2001), where a few days after an individual stepped on a screw, the disability claimant went to the emergency room, where they were diagnosed with "diabetic foot infection," and their foot ultimately had to be amputated.  That disability insurance policy provided that the injury "must result in loss independently of sickness and other causes."  United Omaha Life Insurance Company denied the claim for disability insurance benefits claiming that the loss was not independent of sickness or other causes.  United Omaha ignored that there were infection issues after the initial surgery that led to the need to amputate the foot.

Another Sixth Circuit case that applies to Ohio disability insurance cases is Clark v. Metropolitan Life Insurance Company, 67 F.3d 299 (6th Cir. 1995).  In that case, the disability claimant filed a claim for disability insurance after having a left hip replacement.  Metlife denied the claim because they found a notation in a medical chart that the patient had pain in their left thigh for the past 4 -5 years.  Metlife said that because the pain in the thigh and hip was pre-existing before the surgery, that it was a pre-existing condition.  Metlife had a pre-existing condition clause that read:

"Expenses incurred as a result of an injury, illness, or pregnancy, as diagnosed by a physician or covered provider, which existed prior to the effective date of insurance are not covered by this plan, until twelve months from the effective date of your coverage of the plan, whether the condition was diagnosed before or after the effective date of insurance and whether or not the condition resulted in any symptoms prior to the date of insurance."

The Court did not side with Metlife in that case because the Metlife denial letter simply restated the medical names for the disability claimant's hip conditions, such as enthesopathy of the hip, traumatic arthropathy and osteoarthritis, and then just concluded that they were "pre-existing conditions."  The Court said that Metlife was required by statute and regulations to give the disability claimant specific reasons why it considered those conditions to be pre-existing.  See 29 U.S.C. Sec. 1133, and 29 C.F.R. Sec. 2560.503-1(f).

What to Do if Your Disability Insurance Claim Has Been Denied Due to Pre-Existing Conditions or Otherwise

The moment that you receive the claim denial letter from the insruance company, then the clock starts ticking for you to be able to do anything about it.  There are a lot of things that have to be done in a short amount of time to give you the best chance to overturn the decision to deny your claim.  If you don't do things the right way, then you can blow your chances at winning a lawsuit later on.  An ERISA disability attorney will take care of all those details for you.  Because disability insurance claims are most often governed under a federal law known as ERISA, you need to get an attorney who has specifically dealt with ERISA disability lawsuits before.  Evan T. Engler is an ERISA disability lawyer and partner at the law firm of Harris & Engler.  Harris & Engler is located in Columbus, Ohio, and attorney Evan T. Engler helps clients who's disability claims have been denied all across the Sixth Circuit federal court of appeals, which includes Ohio, Michigan, Tennessee, and Kentucky.  If you'd like to speak to an attorney about your denied disability claim, then ask to speak with Evan T. Engler by calling (614) 610-9988.
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