When fighting a denied disability claim from a major insurer such as Prudential, it can easily end up in a lawsuit. That’s exactly what happened in the case of a testing and development engineer for MIT Lincoln Laboratories who suffered cognitive impairments from a head injury in 2011.
Fortunately, the engineer in this case had a successful outcome and won the lawsuit – but things don’t always end up that way, according to disability insurance attorney Greg Dell. Along with fellow lawyer and disability expert Cesar Gavidia from the Dell & Schaefer law firm, he noted the significance of the lawsuit and how the ruling can help future claimants battling a denied claim from Prudential.
Cesar Gavidia pointed out that a disability insurance attorney sees these types of cognitive cases quite often. The engineer in this denied claim presented with cognitive deficiencies, cognitive decline, and problems in his thought processes and executive functioning. The cumulative effect was an impaired ability to function in his high-level occupation as a development engineer.
Prudential fought back on his claim, however, using several tactics. First, the insurance company suggested that the policyholder obtain a neuropsychological examination to verify cognitive deficiencies – which he did, along with what’s known as “validity testing.”
According to Cesar Gavidia, it’s unusual that the insurer wouldn’t just send the claimant to a third-party vendor who is insurance-company friendly. Instead, they waited until the physician exam results from the claimant came back and then submitted it to their own doctor. This doctor reviewed the results and stated that the science in the testing was outdated based on current protocol and literature.
Apparently, this is a common tactic used for a disability insurance claim denial.
“It’s what we often see,” says Gavidia, “that whole ‘moving target strategy’ employed by disability insurers and the experts that they hire. You go out and obtain the evidence that they say you should have, and they just move the target down the road.”
So when a disabled policyholder gets denied by Prudential – what happens next?
After the Denied Disability Claim
After the neuro exam and initial denial, the MIT engineer appealed, and Prudential denied it again. That’s when the case moved to federal court, and the judge ruled in favor of the claimant. Several things influenced the favorable outcome in this lawsuit.
- First of all, the court found that Prudential had rejected the results of the neuro psych exam for no valid reason. The specialists and treating physicians all concluded that the claimant had post-concussion syndrome, which caused his disability. But Prudential weighed their own doctor’s opinion more favorably than all the existing medical evidence.
- The insurance company used the same neuropsychologist for both the initial claim review and the subsequent appeal – which is not allowed per ERISA guidelines and rules. Whether that was a deciding factor in the court’s decision is unclear, says Cesar Gavidia, but it goes against the concept of a full and fair review.
- Prudential appeared to give no credence or consideration to the fact that the policyholder had already been approved for Social Security disability benefits. Since it is notoriously hard to meet the bar for Social Security approval, it stood out as a glaring lack of research and sincerity on the part of the insurance company.
The court specifically took issue with the fact that Prudential, unlike the Social Security Administration, did not consider any of the engineer’s occupational duties. In other words, the insurance company did not take into account the restrictions, limitations, and how the disability applied specifically to his occupation as a development engineer.
According to Greg Dell, the doctor hired by Prudential merely tried to pick apart the existing neuro psych report provided by the claimant, without performing any new testing or providing proof that the engineer did not indeed have a long-term disability (LTD) with cognitive impairment. Fortunately, the judge in this case looked past the “rubber stamp” version of a disability insurance claim denial by a major insurance provider. Dell notes that it’s sad to see how often policyholders receive unjust denials.
“But luckily,” he says, “they can try to play games and try to strong arm the plaintiff. But at the end of the day, this is a case where the plaintiff prevailed, which is great.”
Most people with long-term disability claim denials are unaware that filing a lawsuit to protect their rights typically requires no “out of pocket” money to get things started. That’s because disability insurance lawyers such as those at the Dell & Schaefer law firm review each case at no cost to determine its validity and the chances of prevailing in court. Many even work on a contingency basis: if they win the case for you, they get their pay from a settlement or an agreed-upon fee for getting you back on claim with the insurance company.