Recently, the Prudential Insurance Company of America (Prudential) was sued by an SAIA truck driver for denial to pay long term disability benefits under the SAIA’s ‘Hourly Employees Long Term disability plan’. A Texas disability lawyer filed the lawsuit on behalf of the plaintiff Mitchell Stiles at the District court for the Northern District of Texas as an action under the Employee Retirement Income Security Act (ERISA).
Prudential Disability Claim Denial Background
In the case of Mitchell Stiles v Insurance Company of America, the plaintiff was a 53 year old man who was formerly employed as a truck driver for the LTL carrier, SAIA, Inc. "Truck Driver" is classified under the Dictionary of Occupational Titles (DOT) as unskilled work and medium occupation with a Specific Vocational Preparation (SVP) of 3. While under the employment of SAIA, Inc. the plaintiff participated under the SAIA’s ‘Hourly Employees Long Term disability plan’. The plan was underwritten and administered by Prudential.
Claim for Prudential Short Term disability Benefits
On July 6th 2007, due to the plaintiff suffering from degenerative and traumatic injuries, the plaintiff ceased working for SAIA, Inc. in the lawsuit filed, the plaintiff alleged that he is suffering from Cervical Stenosis and became disabled on July 9th 2007. As a result of his disability, the plaintiff filed for short term disability benefits with Prudential and was granted short term disability.
Filing for Prudential Long Term Disability Benefits
Subsequently, the plaintiff filed long term disability benefits with Prudential and his claim was approved on November 5th 2007. However, on October 7th 2009 through a letter sent to the plaintiff, Prudential denied further disability benefits to the plaintiff on the ground that the plaintiff did not meet the definition of disability in the plan for "Any Occupation". According to disability lawyer Gregory Dell, "the majority of disability insurance claim denials take place when the definition of disability changes from own occupation to any occupation".
According to the lawsuit filed, under the administrative remedies set forth in the plan, the plaintiff appealed Prudential’s decision to deny him further disability benefits. Further medical records were submitted by the plaintiff to support his appeal. At the same time, the plaintiff was determined as being disabled by the Social Security Administration and issued a favorable decision on his claim for disability benefits.
Prudential on February 1st 2010 informed the plaintiff that it was reaffirming its original decision to deny the plaintiff his claim for long term disability benefits. A second appeal requesting administrative review of the decision to deny disability benefits was filed by the plaintiff with Prudential on July 31st 2010. Additional documentations were also submitted by the plaintiff to support the appeal. Nevertheless, a final denial was issued by Prudential on August 10th 2010.
The Medical Facts
It was stated in the lawsuit that the plaintiff suffered from several medical conditions. He has the following documented medical conditions:
- Multi Level Cervical Fusion
- Cerebral Palsy
- Shortness of breath due to a paralyzed diaphragm,
- Knee Problems
- Abnormalities in the lungs and chest
- Limb Impairment
- Spinal Condition
- Neurological Abnormalities
- Disk Space Narrowing
- Multilevel Disk Osteophyte Complexes
- Central Canal Narrowing
- Cord Compression
- Severe Servical Stenosis at C5-6
- Proterolateral Traction Osteophyte
- Neural Foraminal Stenosis
- Back and Joint Pains
- Residue Myelopathy
It was alleged that the overall result of the plaintiff medical conditions was a severely limited range of motion, a restriction in activities and chronic pains. The plaintiff argued that he suffered from the above mentioned symptoms and they were not based merely on his own allegations. Because of these symptoms, the plaintiff argued that he was unable to maintain the concentration and the pace required to partake in competitive employment on full time basis hence satisfying the plan definition of being disabled for "any occupation". The plaintiff contended that despite his condition, Prudential persistently denied the plaintiff’s claim for disability benefits.
Relief sought in the Legal Action
Having exhausted all his administrative remedies, the plaintiff therefore has no choice but to file an action under ERISA with the court to seek the following relief:
- Declaratory and injunctive relief finding that the plaintiff is entitled to all prior short term and long term disability benefits not yet paid;
- An order for Prudential to pay all future short term and long term disability benefits;
- An award of reasonable attorney fees and cost;
- Any other relief that is just and appropriate.
About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.