As those who suffer from medical conditions such as fibromyalgia and chronic fatigue syndrome know, these illnesses can incapacitate an individual physically and mentally. No current treatment has proven totally effective against these infirmities and in many cases the illness becomes worse over time. Many clients come to us at DI Law Group complaining that despite having provided their insurance company with medical evidence proving that they are no longer able to work, the insurance carrier has either failed to make a decision and is “surveillance” the claim or has unfairly denied benefits claiming there is insufficient evidence upon which to grant benefits. One such client, “Ms. Doe”, a professional who truly enjoyed her occupation and worked as long as physically possible, contacted us after her claim for benefits had been unfairly denied by Prudential. Included with her application were medical records with examination findings confirming her medical diagnoses and detailing her physical limitations and decline. During its investigation of the claim, Prudential put her under surveillance, sent her ongoing requests for information, had one of their own “independent” physicians review her medical records and the surveillance tape, and misrepresented her occupation and limitations to the vocational specialist assigned to review her claim. Not surprisingly, Prudential’s physician determined that there was no medical evidence to substantiate her reported complaints of pain, fatigue, and limitations and thus found that she could return to her job on a full time basis.
Ms. Doe came to us quite distraught. She was shocked and embarrassed by Prudential’s claim that she was “faking” her disability claim and angry at the suggestion that she would prefer to sit home in pain and not working for 60% of her salary, rather than spend her time at a job she truly enjoyed and performing work in which she took great pride. When Ms. Doe hired us, we immediately contacted Prudential and requested Ms. Doe’s claim file including all internal memos, surveillance videos and reports, and all documents in any way related to her claim. At our request, the full claim file was provided and our review found a number of disturbing inconsistencies. Additionally, the surveillance video was reviewed and we provided Ms. Doe with the opportunity to explain the activities observed on the tape. We then contacted her treating physicians and procured statements from each which specifically responded to issues raised in Prudential’s medical reports and claim summaries, as well as by the videotaped surveillance. Additional statements from colleagues, friends and family were also procured; we addressed the vocational consultant’s findings; we obtained information about Prudential’s “experts”; and we provided Prudential with extensive and current information about Ms. Doe’s illnesses. Upon receipt of the Appeal filed by our firm, Prudential contacted the attorney to advise that it was necessary to send Ms. Doe to an independent medical examination (IME) by a doctor of their choosing before a determination in this matter could be made. After several letters and telephone calls, Prudential agreed to our demands regarding the IME and Ms. Doe presented herself to the doctor for examination. Following the IME, Prudential tried to further stall a determination claiming more information was needed. With constant pressure and numerous letters from us reminding Prudential of the law and its contractual obligations, Prudential finally approved the claim, paid Ms. Doe all back benefits due to date, and agreed that she remained unable to perform the duties of her occupation.
Even after the denial was approved and benefits reinstated, we continued to represent Ms. Doe because the definition of Disability would change after she received 24 months of Long Term Disability benefits. Initially she was considered disabled if the medical records showed that she was unable to perform the material duties of her own occupation. However, after 2 years she would only be considered disabled, and thus eligible for ongoing disability benefits, if she provided proof that she was unable to perform the material duties of any occupation for which she is qualified based on her education, training, and experience. Thus, even after the denial was overturned we continued to provide Prudential with evidence of Ms. Doe’s declining health and limitations. We updated her physician’s statements and directly addressed her limitations providing as much objective evidence as possible. During the Any Occupation evaluation, Prudential again had Ms. Doe followed and scheduled another interview with her. Ms. Doe complied with all requests for information and her claim was approved beyond the Any Occupation period. She remains on claim at this time and we continue to represent her and provide Prudential with updated medical evidence and proof of her limitations. At this time, Prudential appears convinced they are going to be paying Ms. Doe through her maximum benefit period and we are thus negotiating a lump sum buyout of her claim.
Whether applying for disability benefits, appealing a denial of benefits, negotiating a lump sum buyout, or filing a lawsuit, it is extremely important that an insured fully understand their rights under the disability policy, the insurance company’s legal and contractual obligations, as well as the policy’s terms, exclusions and limitations. If you have any questions about your policy or would like to discuss your disability claim with us, please contact us for a free consultation at (866) 363-3628 or through our website www.dilawgroup.com.