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Bristol Myers Director with Mental Nervous Disorders Wins Prudential Disability Appeal

The case involves an associate director working in research and development for Bristol Myers Squibb, a position requiring high-level cognitive functioning. The client had an approximately 11-year history of depression and anxiety, along with diagnoses of bipolar disorder and fibromyalgia. She initially stopped working in the summer of 2024 but was eventually able to attempt a return to full-time employment. That return lasted less than a month before her conditions again prevented her from working, and she entered an intensive outpatient treatment program.

When the client sought long-term disability benefits, the insurer denied her claim. Its decision relied primarily on a file review performed by a physician certified in psychology and neuropsychology. Despite the client’s intensive outpatient treatment and extensive history of mental health conditions, the reviewer concluded that the evidence did not demonstrate impairment severe enough to prevent her from performing her occupation. The insurer also pointed to her ability to perform activities of daily living and focused primarily on her psychiatric diagnoses while giving less consideration to the physical effects of her fibromyalgia.

Attorney Stephen Jessup developed an appeal addressing both the mental and physical components of the client’s disability. This was particularly important because the policy provided only six months of long-term disability benefits under the own-occupation definition before changing to an any-occupation standard. By the time the appeal was being developed, it was therefore necessary to demonstrate not only that she could not return to her cognitively demanding position but also that she could not perform another qualifying occupation under the policy.

The appeal included several forms of additional evidence:

• Customized questionnaires, letters, and responses from the client’s treating providers addressing her specific restrictions and limitations.
• Cognitive testing that demonstrated deficits associated with her depression and anxiety that interfered with the demanding cognitive tasks required by her occupation.
• Additional medical records from her rheumatologist that had not been included in the insurer’s earlier review.
• A Functional Capacity Evaluation to document the physical limitations associated with her conditions, including whether she could sustain even sedentary work.
• Detailed responses from treating physicians addressing the insurer’s peer-review conclusions and explaining why they disagreed.
• Evidence connecting both her psychiatric and physical limitations to the actual requirements of her occupation and other potentially qualifying work.

Despite this additional evidence, the insurer denied the first appeal. It argued that the deficits identified through the cognitive and functional testing were not sufficiently reflected in the client’s existing treatment records. The insurer also declined the request for an independent medical examination, maintaining that an examination was not required and would not be relevant given the amount of time that had passed since the client’s date of disability.

While Jessup was considering whether to pursue a voluntary appeal or proceed toward litigation, the client was approved for Social Security disability benefits on appeal without needing to proceed to a hearing. Because the long-term disability claim was governed by ERISA, Jessup wanted the Social Security claim file and supporting evidence included in the administrative record. He therefore recommended pursuing the voluntary appeal and incorporated the Social Security evidence, additional physician questionnaires, and medical opinions into the submission.

The customized physician questionnaires were designed around the client’s specific conditions and occupational requirements. Rather than simply asking treating doctors to respond generally to the insurer’s peer-review reports, the questionnaires asked targeted questions about whether they agreed or disagreed with particular conclusions, the medical reasons supporting their opinions, appropriate restrictions and limitations, and expectations for improvement. This helped connect the medical evidence directly to the functional requirements of the client’s work.

The voluntary appeal ultimately succeeded more than a year after the original denial. The insurer reversed its decision and approved the claim under both the six-month own-occupation period and the subsequent any-occupation definition of disability. Importantly, the client’s policy does not contain a mental health or fibromyalgia-related benefit limitation, allowing her to remain eligible for ongoing benefits as long as she continues to satisfy the policy’s disability requirements.

This case demonstrates the importance of developing both the medical and functional evidence when a disability involves overlapping psychiatric, cognitive, and physical conditions. The client’s appeal required more than establishing diagnoses of depression, anxiety, bipolar disorder, and fibromyalgia. By documenting cognitive deficits, physical limitations, physician support, occupational demands, and the Social Security disability determination, the appeal established how those conditions actually prevented her from sustaining qualifying employment under both definitions of disability in the policy.