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
  • Insomnia
  • Neuropathy
  • 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.

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It’s not unusual for a long-term disability insurance company to ask a claimant to apply for Social Security Disability Income (SSDI) benefits. Why? When claimants receive SSDI benefit payments, the disability insurance company will offset the monthly benefit payment paid to the claimant by the amount of money the claimant receives from SSDI.

Most disability insurance companies  hire a third-party to help the claimant obtain SSDI – especially if the claimant is experiencing difficulty obtaining Social Security disability income benefits alone. 

In what appears the win–win–win situation for the claimant, the ultimate winner is the  disability insurance company because they end up saving money in this well-calculated business decision.

Here is an example of what can happen.

Due to unspecified disabling conditions that precluded her from working on her own and, presumably, any occupation, Anita James of Kentucky was able to receive the maximum amount of short-term disability benefit payments from Prudential Insurance Company of America (Prudential). Ms. James also received long-term disability benefit payments during the first two years of her being completely and totally disabled. After that, however, Prudential terminated Ms. James’ disability benefit payments.

With the help of a Kentucky disability lawyer, Ms. James filed a civil complaint against Prudential in United States District Court in the Western District of Kentucky, the Louisville Division for terminating her long-term disability benefits governed by ERISA.

Under the terms of the policy, if the claimant is approved for Social Security disability income, Prudential can subtract the amount the claimant receives as SSDI from the amount Prudential pays in disability benefit payments to the claimant. In Ms. James’ case, Prudential hired and paid a company named Allsup, whose main focus is to assist disability claimants with SSDI claims, to obtain SSD I benefits for her stating, "[she] was totally disabled from any gainful occupation."

According to the civil complaint, "Prudential compensated Allsup for obtaining the SSDI benefit (which resulted in a reduction in Prudential’s LTD benefit payments to Ms. James – the substantial financial savings) and for obtaining reimbursement of prior LTD payments (which resulted in an additional financial windfall to Prudential)."

Shortly after receiving SSDI Benefits,  Prudential decided to terminate Ms. James’ long-term disability benefit payments. This comes on the heels of Allsup successfully obtaining Social Security disability income payments for Ms. James at Prudential’s request. 

Prudential’s decision to terminate Ms. James’ LTD benefit payments, according to Ms. James and her disability lawyer, stemmed from "Prudential’s internal policy of requiring claims personnel to follow the recommendations of its own physician recommendations, without regard to the participants treating physicians, precludes any participant from receiving a full and fair review."

In conjunction with that conclusion, Ms. James and her disability lawyer state that Prudential:

  • disregarded the recommendations of Ms. James’ treating physicians, Allsup, Social Security findings, and Ms. James’ medical records
  • did not question the recommendation of medical experts who did not examine Ms. James
  • gives claims personnel incentives foreclosing claims including terminating LTD benefits
  • enjoyed and benefited from the financial gain from the reimbursement of Ms. James’ long-term disability benefit payments to them
  • employs these practices regularly

For her relief, Ms. James seeks the following:

  • for Prudential to disgorge itself of all profits gained on the long-term disability benefit payments
  • long-term disability benefit payments she is due under the terms of the policy
  • prejudgment interest
  • attorney’s fees
  • all other costs associated with litigation

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.

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Disability Blog & Cases:
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Disability Blog & Cases:
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Disability Insurance Law TV:
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Disability Blog & Cases:
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Disability Blog & Cases:
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Disability Blog & Cases:
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Disability Insurance Law TV:
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Disability Blog & Cases:
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Disability Blog & Cases:
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Disability Blog & Cases:
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Disability Insurance Law TV:
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Disability Blog & Cases:
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