Our Client v. Prudential Ins. Co. of America
Prudential arbitrarily and capriciously ignored its own experts, and as a result, the court ordered Prudential to reconsider its decision that our client was not sufficiently disabled from fibromyalgia.
Our client, suffered from intense fibromyalgia, which rendered her unable to continue in her career as a Commercial/Consumer Lender-Vice President at a well-known bank. When her condition forced her to step down from her career, Prudential refused to honor its promise of paying her long-term disability benefits.
We helped our client through the complex process of administratively appealing Prudential’s decision several times. Though we provided compelling medical evidence of our client’s disability, including statements from several of her examining physicians, Prudential continued to deny the claim. And, despite the evidence we submitted, Prudential claimed that our client did not have a “significant psychiatric impairment which would prevent [her] from performing the material and substantial duties of [her] own occupation.” We appealed with additional evidence and a letter from our client’s primary care physician clearly stating that in his medical opinion, she was “disabled from substantial performance of any job for which she is reasonably trained and educated.” Prudential again denied our appeal, claiming that fibromyalgia “in and of itself is not indicative of a totally disabling condition.”
We appealed with an additional expert statement from another physician corroborating our position that she was totally disabled on account of her fibromyalgia. Prudential then sent the records to one of its hired consulting physicians. Without personally examining the claimant, Prudential’s consulting physician concluded that her “physical complaints were manifestations of her psychiatric difficulties, rather than the reverse,” and that she did not suffer a total disability that would make her unable to work. This physician did, however, recommend a psychiatric evaluation to investigate the true nature of our client’s condition and possible disability. Prudential denied the claim again, without ordering this psychiatric evaluation.
We appealed once more to provide another expert medical opinion addressing the opinion of Prudential’s consulting physician, as well as providing a copy of our client’s recent approval for social security disability benefits. Prudential sent our client’s medical records to another of its consulting physicians for review, who also determined, without ever personally examining our client, that she was not disabled from her sedentary job. Prudential then denied our final appeal, relying on this consulting physician’s opinion.
We then brought action in federal court under ERISA’s civil enforcement provision—29 U.S.C. § 1132(a)(1)(B). The court evaluated Prudential’s decision under the usual deferential arbitrary and capricious standard. The court found that Prudential was unreasonable in not following its own expert physician’s suggestion that our client be evaluated by a psychiatrist to determine the true extent of her disability. This amounted to an unreasonable failure to fully investigate the claim.
Furthermore, the court noted that even though Prudential referenced in its denial letters the many pieces of evidence that supported our client’s disability, “Prudential arbitrarily refused to credit or attached little to no significance to this evidence, which the Court [found to be] reliable” evidence. Instead, Prudential dealt with the favorable evidence by simply stating that it was not enough to support the existence of a disability.
The court ultimately agreed with us that Prudential’s failure to credit the evidence supporting our client’s disability, while also ignoring the recommendations from its own experts, rendered its denial determination arbitrary and capricious. The remedy for this, according to the court, was to remand the decision back to Prudential to reconsider its determination in light of the court’s findings. We continued our representation of our client against Prudential and secured a judgment to have an award toward our client’s attorney’s fees paid by Prudential.