Filing Long-term Disability Appeals with Prudential
Prudential is one of the largest LTD companies offering policies today. If you wish to appeal a denied claim you should seek legal assistance.
Author: Attorney Lonnie Roach
Prudential Insurance Company is one of the largest insurance companies in the world. Prudential began as the Widows and Orphans Friendly Society in 1873 and later became The Prudential Insurance Company of America. The company was founded by John F. Dryden who modeled Prudential after the British Prudential Assurance Company which offered industrial insurance to workers.
The original aims of the company were to provide relief in sickness and accident for people of “meager means,” pensions for aging workers, and burial funds for children and adults.
In 1896, its famous logo, “The Rock of Gibraltar,” was created suggesting that Prudential had the “Strength of Gibraltar.” This logo, along with “Get A Piece of the Rock,” are still used today.
As one of the leading providers in group insurance, Prudential provides a full range of group life insurance, short-term and long-term disability insurance, and group corporate, bank-owned and trust-owned life insurance as well as a variety of financial services for individuals, groups and institutions.
Among the products Prudential markets are:
- Life Insurance
- Health Insurance
- Disability Insurance
- Annuities and IRAs
- Financial Planning Services
- Home Equity and Mortgage Services
Prudential is an international company with operations in the U.S., Asia, Europe and Latin America.
The company boasts $1.366 trillion in assets under management and serves individual and institutional customers in over 40 countries. Prudential has approximately 49,000 employees worldwide, dividing its services into three divisions:
- U.S. Retirement Solutions and Investment Management Division
- International Insurance Division
- U.S. Individual Life and Group Insurance Division
Prudential’s claim process attempts to simplify the employee’s experience by providing tools that allow for different methods of communication according to an employee’s preference.
Those methods include:
- Two-way texting to enable an employee to provide necessary information quickly
- A claim status tool that provides real-time status and when to expect payment
- On-line documents and forms for uploading quickly
- Phone contact with Prudential staff 24/7 as well as e-mail
The contact information for Prudential is:
The Prudential Insurance Company of America
Disability Management Services
JP. O. Box 13480
Philadelphia, PA 19176
Tel.: 800-842-1718; Fax: 877-889-4885
If you have been denied disability benefits don’t give up! Contact a Disability lawyer at 512-454-4000 for a free consultation and get the benefits you deserve.
Prudential’s LTD plans cover more than 2.1 million lives.
Before filing a claim for short-term or long-term disability with Prudential, be sure to review your policy for its terms and Prudential’s definitions of “disability.”
The definition of disability which applies during the regular occupation period states that a disabled person “cannot perform the material and substantial duties of the occupation they performed when their disability began and they sustain a 20% loss in income.
Prudential looks at the occupation as it is normally performed rather than how the work is done for a particular employer or at a specific location.” The “gainful occupation” definition of disability is one “that employees can perform (based on education, training, or experience) and which provides – or can provide – a re-determined percentage of pre-disability earnings.” The “catastrophic” definition of disability applies when a person is “unable to perform at least two activities of daily living.”
Employees who wish to file a claim for short-term or long-term disability can find guidance on Prudential’s website, but there are three required steps:
- Notify your employer of your absence and inform them that you’ll be filing a disability claim. Ask your employer to complete the Employer’s Statement and submit it to Prudential.
- Complete all sections of the Employee’s Statement and submit it to Prudential. You may also complete and submit the Employee’s Statement online to save time at the beginning of the process. Go to https://mybenefits.prudential.com/.
- Ask your doctor to complete the Attending Physician’s Statement and submit it to Prudential.
Prudential considers a claim to be filed when the Employer’s Statement, Employee’s Statement, and Attending Physician’s Statement have been submitted and there are specific elimination period requirements for Short-Term Disability and Long-Term Disability coverage.
The company will notify you of its determination within 45 days of the filing date. This period of 45 days may be extended by 30 days if it is deemed necessary due to “matters beyond the control of the Plan” and may be extended for an additional 30 days due to “matters beyond the control of the Plan.” As with all LTD insurance claims, it is important that you provide all information requested when it is requested to prevent delays in processing your claim or a denial of your claim. Document all phone calls and e-mails with Prudential and keep up with requested monthly reports.
If your claim is denied, you or your representative will receive a notice stating:
- the specific reason(s) for the denial,
- references to the specific plan provisions on which the benefit determination was based,
- a description of any additional material or information necessary for you to perfect a claim and an explanation of why such information is necessary,
- a description of Prudential’s appeals procedures and applicable time limits, including a statement of your right to bring a civil action under section 502(a) of ERISA following your appeals, and
- if an adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon request.
Because Prudential long-term disability policies are marketed primarily to institutional clients for employee and membership benefit plans, the plans are governed by The Employee Retirement Income Security Act or ERISA which requires a claimant to “exhaust administrative remedies” before filing suit.
If a claim is denied, claimants have 180 days to appeal and the insurer has 90 days to consider the appeal which equals 270 days the disabled person is without income. Claimants may be advised to file for Social Security Disability Income when filing a claim, but insurers may deduct any Social Security Income from insurance benefits and, if a claimant does not file for SSDI, the insurer may claim the disabled person has breached an LTD policy requirement. ERISA permits insurers to administer their own plans and a denial can only be reversed by demonstrating that the insurer abused that discretion – which is very difficult to do. If an internal appeal is denied, filing suit in U.S. District Court is a claimant’s last option.
The only medical justification referenced in the denial letter for Prudential’s determination that another client’s disability was due to mental illness, and thus limited to 24 months of benefits under her policy, was a Medical Evaluation by a reviewing physician. This doctor clearly stated that our client was totally disabled but felt she was possibly in a psychotic state on the day of the examination. This doctor also offered that “this may very well be related to lupus or some sort of arthritis.” This, of course is possible. Systemic Lupus Erythematosus is well known to cause Lupus Psychosis. Lupus Psychosis is not, however, a mental illness. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, it is a “psychosis due to a general medical disorder.” Our client suffered from numerous other documented, serious health conditions for which her treating physician had certified her as being totally disabled. She had also been awarded SSDI benefits. The reviewing physician admitted that our client’s chronic pain alone rendered her disabled, but Prudential chose to deny her benefits. We filed suit on her behalf, and Prudential settled, awarding our client a lump sum.
Another client, in San Marcos, had a progressive neurogenic disease.
This disease caused wasting syndrome of her left arm and deltoid triceps and biceps groups. Our client also had EMG-confirmed neurogenic atrophy of her bilateral lower extremities and wasting in those extremities. She had a surgically inserted pain pump which dispensed a pain medication 100 times as powerful as morphine, and further required narcotic patches to attempt to control her pain. She required a wheelchair to move any significant distances and was eventually confined to an assisted living center. She was found to be totally disabled from any gainful activity by the Social Security Administration. Prudential wrongfully denied her LTD claim. We got her benefits reinstated.
ERISA disability disputes can be long and drawn out and few disabled people have either the resources or physical stamina to fight with a large insurance company.
That is why it’s important to have a qualified attorney with extensive experience in LTD disputes and ERISA to organize and manage your case. Partner and long-term disability attorney Lonnie Roach of Bemis, Roach & Reed has successfully overturned denials of disability benefits at the administrative level, in United States District Court, and at the United States Court of Appeals. Presently Lonnie represents clients who have been denied or lost insurance, long term/ ERISA or Social Security disability benefits in all four federal districts in Texas. If you have been denied long term disability benefits, Bemis, Roach & Reed offers a free consultation to determine if we can assist you in obtaining or reinstating those benefits. Call 512-454-4000 and get help today.
Author: Attorney Lonnie Roach has been practicing law for over 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion rated by Martindale Hubbell. Through his extensive litigation Mr. Roach obtained board certifications from the Texas Board of Legal Specialization. Lonnie is admitted to practice in the United States District Court - all Texas Districts and the U.S. Court of Appeals, Fifth Circuit. Highly experienced in Long Term Disability denials and appeals governed by the “ERISA” Mr. Roach is a member of the Texas Trial Lawyers Association, Austin Bar Association, and is a past the director of the Capital Area Trial Lawyers Association (Director 1999-2005) Mr. Roach and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.
Bemis, Roach & Reed has helped clients who are disabled from a wide variety of medical conditions. If you are unable to work due to any of the following conditions and have been denied disability benefits, contact us. We would like to help.
- Acid Reflux
- AIDS / HIV
- Alcohol Dependence
- Alzheimer's Disease
- Amyotrophic Lateral Sclerosis ("ALS")
- Autoimmune Disorder
- Back Pain
- Bipolar Disorder
- Bladder Control
- Blood Disorder
- Brain Aneurysm
- Brain Tumor
- Breast Cancer
- Bulging / Herniated Disc
- Cancer (all kinds)
- Car Accident
- Carpal Tunnel Syndrome
- Cerebral Atrophy
- Cerebral Palsy
- Cervical Disc Disease
- Chronic Fatigue Syndrome
- Chronic Obstructive Pulmonary Diseases (COPD)
- Chronic Pain Syndrome
- Congestive Heart Disease
- Congnitive Dysfunction
- Coronary Dysfunction
- Crime Injury
- Crohn’s Disease
- Cystic Fibrosis
- Degenerative Disc Disease
- Down Syndrome
- Epstein-Barr Virus
- Essential Tremor
- Falls and disability
- Gastrointestinal Reflux
- Hearing Impairment
- Heart Arrhythmias
- Heart Failure
- Hepatitis C
- Herniated / Bulging Disc
- High Blood Pressure/Hypertension
- Hip Replacement
- Hodgkin’s Disease
- Huntington’s Disease
- Interstitial Cystitis
- Irritable Bowel Syndrome (IBS)
- Ischemic Heart Disease Disability
- Kidney Disease
- Knee Disorder/Replacement
- Liver Cancer
- Liver Disease
- Lumbar Disc Disease
- Lumbar Radiculopathy
- Lung Cancer
- Lyme Disease
- Macular Edema/Degeneration
- Memory Disorder
- Menieres Disease
- Mental Illness
- Migraine Headaches
- Multiple Myeloma
- Multiple Sclerosis
- Muscular Dystrophy
- Myofascial Pain Syndrome
- Neurocognitive Disorder
- Parkinsons Disease
- Peripheral Neuropathy
- Post-polio Syndrome
- Post-Traumatic Stress Disorder (“PTSD”)
- Prostate Cancer
- Reflex Sympathetic Dystrophy (“RSD”)
- Rheumatoid Arthritis (RA)
- Seizure Disorder
- Sjorgen's Syndrome
- Skin Cancer
- Sleep Apnea
- Speech Disorders
- Spinal Stenosis
- Systemic Sclerosis
- Temporal Mandibular Joint Dysfunction (TMJ)
- Throat Cancer
- Traumatic Brain Injuries
- Vision Impairment
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