Recently a lawsuit was filed at the District Court for the District of New Jersey against the Prudential Insurance Company of America (Prudential) for failure to pay long term disability (LTD) benefits to a disabled teacher for West Orange Board of Education. In Janel Braun v The Prudential Insurance Company of America, the plaintiff Janel Braun alleged that Prudential had wrongfully denied the plaintiff her claim for LTD benefits.
The Nature of the Complaint
The plaintiff Janel Braun was a school teacher employed by the West Orange Board of Education. Whilst employed by the West Orange Board of Education, the plaintiff participated in a health and welfare plan that was offered by the New Jersey Education Association Member Fund, a plan underwritten and administered by Prudential. Under the plan, disability was defined as a person who is unable to perform the material and substantial duties of their regular occupation due to injury or sickness and suffered a 20% or more loss in monthly earnings as a result of that sickness or injury.
Due to severe pain relating to her sinus thrombosis, the plaintiff stopped working on April 29th 2005. The plaintiff’s medical records were said to support the fact that she was unable to perform the material and substantial duties of her occupation. Subsequently, due to her disability, the plaintiff filed a claim for disability benefits with Prudential and was approved for LTD benefits on May 30th 2005. The LTD benefits were paid out to the plaintiff until May 29th 2007.
Disability Definition changes After 24 Months
Under the policy, the plaintiff was be subjected to a review of eligibility after receiving 24 months of LTD benefits. The review was to determine if the plaintiff satisfied the definition of disabled by not being able to perform the duties of any gainful employment for which she is reasonably suited by education, training or experience. To be considered gainfully employed, the plaintiff had to earn at least 66.33% of her pre-disability income. In the plaintiff’s case, she had to earn at least $14.55 per hour to be considered gainfully employed. Upon conducting an employability assessment, Prudential determined that the plaintiff could be employed as an information clerk, a tutor, a telephone solicitor or as a routing clerk. It was asserted by Prudential that these occupations have an hourly wages of $15.00 to $18.00 which exceeded the plaintiff’s minimum threshold to be considered gainfully employed.
Thus, on April 9th 2009, the plaintiff was informed that she did not meet the definition of disability under the plan and hence was not eligible for further payment of LTD benefits effective May 30th 2009. The plaintiff in response submitted an appeal to Prudential on November 16th 2009, together with further medical documentations supporting her claim. She also submitted details of her eligibility for Social Security Disability Benefits. Nevertheless, the plaintiff’s appeal was rejected on March 18th 2010. Further to this rejection, another appeal was submitted to Prudential by the plaintiff on September 2nd 2010. This appeal was also denied by Prudential.
According to the lawsuit filed, the plaintiff contended that she had been disabled since 2005. In addition since November 2007, the plaintiff had been receiving Social Security Disability Benefits as the Social Security Administration had deemed her disabled and unable to be gainfully employed based on the same medical documentations provided to Prudential. The plaintiff further alleged that the chronic daily pain associated with her disability rendered it impossible for her to be gainfully employed as an information clerk, a tutor, a telephone solicitor or as a routing clerk. Due to Prudential’s decision to terminate her LTD benefits, the plaintiff argued that Prudential had:
- Acted in contravention of the provisions of the Employee Retirement Income Security Act of 1974 (ERISA)
- Committed material breaches of its contractual obligations under the plan
- Breached the Covenant of Good Faith and Fair Dealings
- Breached its Fiduciary duty to act solely in the interest of the Plaintiff
Claim for Relief
Due to the above mentioned breaches, the Plaintiff is seeking the following relief from the Court:
- Reinstatement of LTD benefits under the plan
- Payment of all retroactive benefits
- Payment of ongoing benefits
- A determination that the plaintiff is entitled to future benefits
- An award of attorney fees and costs
- Compensatory damages
- Punitive Damages
- Any other relief deemed just and proper by the Court
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.