You Can Fight Back Against an Unfair Prudential Disability Insurance Benefit Denial
The Prudential Insurance Company of America (Prudential) was No. 48 on the Fortune 500 list for 2017, generating as much as $41.47 billion in recent years. Many may question how Prudential earned its impressive financials, even after it recently settled a class action lawsuit for nearly $40 million. The lawsuit alleged that Prudential violated federal law by failing to pay certain disability insurance benefits to military service members and their families in inappropriate ways.
Prudential—along with other billion dollar disability insurance companies understand they can increase profits by denying legitimate claims or giving policyholders the runaround. Unfortunately, insurance companies act in bad faith more often than one might imagine. By denying disability claims outright or convincing policyholders to settle claims for less money, insurers bank on you not putting up much of a fight. Disability insurers can also delay claims rather than paying them in a timely manner. If you believe Prudential unfairly treated you regarding your individual or employee sponsored group disability plan, DarrasLaw can help.
If you feel that Prudential is dragging out your claim until you are too sick, too disabled, or too strapped for financial resources to fight back, call DarrasLaw.
DarrasLaw is the nation’s top disability law firm. We have seen, evaluated and resolved more individual and long-term disability cases than any other firm in the United States. We have recovered nearly $1 billion in unpaid insurance benefits on behalf of our clients. We are here to help you if Prudential or another disability insurance company improperly denied your valid claim for disability insurance benefits.
Please call (800) 458-4577 for immediate help today. We offer free policy and claim consultations and will fight for you after a wrongful delay or bad faith denial of your disability insurance benefits by Prudential.
The More You Know About Your Prudential Policy, the Better.
Prudential’s Long-Term Disability (LTD) Insurance, as well as other LTD plans, offer income protection. This means that Prudential will replace a portion of your annual income in the event that a covered sickness or accidental disability renders you unable to work for a period of time.
A primary difference between LTD and Short-Term Disability (STD) plans is the amount of time the beneficiary can receive monthly, monetary disability benefits. As with all insurance companies, Prudential only covers certain disabilities—categorically excluding others. Furthermore, Prudential excludes certain causes of injuries—regardless of the disabling effects that may ensue. Understanding the specific features and policy provisions of your plan can help you to avoid delays and wrongful denials. It can also help you to know when and if you should fight back.
The following circumstances are generally, categorically excluded by Prudential. You will not receive disability insurance benefits, for any period of disability, if your disability was caused by:
- Any intentionally self-inflicted injury
- Any war or act of war, including undeclared war
- Active participation in a riot
- Commission of a crime for which you have been convicted under state or federal law
Every individual and group disability insurance policy will provide the definition on which the insurer relies to determine a claimant’s eligibility to receive benefits. The term disability or disabled as defined by your policy may not be the way you understand those terms in general conversation or daily life. Understanding how disability is defined and applied in your policy will help you understand the documentation you will likely need to successfully claim disability insurance benefits through Prudential. Keep a copy of everything you sent or received.
Prudential’s most generous individual and group policies consider individuals disabled when it determines that due to their sickness or injury, they are or have been:
- Unable to perform the material and substantial duties of their regular occupations. This does not mean that individuals cannot perform the specific duties for their job, but their disabilities prevent them from performing their occupation in the usual and customary way.
To determine this, Prudential looks to whether individuals have:
- A total disability or a 20 percent loss or more in monthly earnings—and you are partially disabled.
Also, Prudential’s definition of disabled requires that individuals are:
- Under the regular care of a treating doctor or the most appropriate care for condition causing disability.
The definition of total disability usually protects insureds for 24 months in their own occupation. After 24 months of payments, Prudential only continues to consider you disabled if, due to the same sickness or injury, you are:
- Unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience and are appropriately cared for
- If you are under the regular care of a treating doctor
Furthermore, Prudential—and all insurance companies—can reject at their peril your treating doctor’s evaluations and order their own independent evaluations with doctors or examiners of their choice. While this is, in fact legal, it can often signal bad faith on the part of Prudential and other insurers where the reviewers qualifications, education, training and experience pales when compared to the treating doctor.
Can Prudential Do This? Recognizing Insurance Bad Faith
Insurance companies deny claims that do not satisfy reasonable conditions of coverage. All individual and group insurance companies, however, have an obligation to act in good faith. When an individual policyholder files a claim with Prudential, or any disability insurer, the law requires that the insurer manage the claim ethically and lawfully—otherwise known as acting in good faith. This means that insurance companies should not get away with simply looking for ways to avoid paying righteous claims—this unlawful, unethical practice is known as acting in bad faith. Bad faith disability claims and lawsuits can arise in many ways, including, but not limited to:
- Unjustified denials of coverage
- Failure to reasonably investigate a claim
- Failing to make a claim decision within a reasonable amount of time
- Failure to relate relevant information to the claimant (or person filing the claim)
- Paying less than what the policyholder is really entitled to
- Improperly reviewing appeals of disability claim denials by minimizing the evidence
Did You Receive an Individual or Group Claim Denial Letter From Prudential?
An initial denial from Prudential is, unfortunately, common. If your claim for disability insurance benefits was initially denied, you may have the right to appeal. If your group disability appeal is denied, you must generally, timely and administratively appeal before you have the right to file a federal lawsuit under ERISA. If Prudential acted in bad faith in denying your individual disability claim, you may have grounds to file a lawsuit without appealing.
Prudential, like all disability insurers, has an obligation to deal with you fairly and in good faith. Examples of bad faith actions by Prudential and its disability claims investigators that may be a precursor to a wrongful denial of disability insurance benefits include:
- Requests to complete endless duplicative paperwork that ‘was allegedly never received’
- Delays in determining your right to disability insurance benefits because medical records were allegedly never updated
- Failure to fully and fairly review your subjective and objective medical evidence of disability
- Denial of coverage because of an alleged misrepresentation or a pre-existing condition
- Switching claim representatives repeatedly to overwhelm and confuse the insured
- An incorrect notice of overpayment after you received disability insurance benefits from Prudential
- Denied benefits after an initial approval and payment of disability insurance benefits due to minimizing your many medical conditions
A rejection of your claim for disability insurance benefits by The Prudential Insurance Company of America is clearly not the end of the claim road. As an insured under a private disability insurance policy you may be able to sue directly if your claim was denied. You generally have to timely appeal your group claim of disability insurance benefits before filing an ERISA complaint in Federal Court.
The bottom line is that you need to have best legal and claim strategy. At DarrasLaw, we can help you evaluate your options and take action on the one most appropriate.
Prudential’s Patchy Claims Past
Insurance companies bank on your decision to not fight back! If your disability insurance company delays or denies your claim, don’t assume that their conduct is lawful. Though insurance companies like Prudential are big and often intimidating, they are not above the law.
At DarrasLaw, we have unmatched litigation and appeal experience in fighting the big disability insurance companies—and winning. We are fully committed to our mission: to serve the disadvantaged and disabled by ensuring they receive what their insurance companies rightfully owe them and in good faith. We are so passionate about this mission we fight the toughest denials in the most difficult jurisdictions all across America. Call us today. Consultations are free, and we can help determine if you should fight back!
Here is an example of Prudential’s patchy claims history.
- Scibelli v. Prudential Insurance Company of America
Scibelli served as the executor of Walter Jajuga, who ultimately died. This suit was brought on his behalf. Alleging, substantial mishandling of Prudential’s administration of Jajuga’s disability claim.
Through Prudential, Jajuga had two policies: a disability insurance policy and a life insurance policy. The suit was ultimately brought against Prudential after it denied Jajuga’s claim under his disability policy and throughout his administrative appeals—but, in direct contradiction, Prudential agreed that Jajuga was totally disabled for purposes of a separate individual life insurance policy.
Jajuga was enrolled in his employer’s group life insurance policy. This means that the Employee Retirement Income Security Act of 1974 (ERISA) governed the group plan. Jajuga was also a participant in a self-insured long-term disability (LTD) insurance benefits plan.
After he stopped working due to his disability, Jajuga applied for a waiver of the premiums that he paid monthly—which Prudential allows for individuals who, due to total disability, cannot work. For the purpose of his policy’s premium waiver, Prudential defined total disability as:
Total Disability: You are “Totally Disabled” when:
(1) You are not working at any job for wage or profit; and
(2) Due to Sickness, Injury or both, you are not able to perform for wage or profit, the material and substantial duties of any job for which you are reasonably fitted by your education, training or experience.
Upon denying his claim, Prudential only stated that he was not eligible for a premium waiver because he was not “totally disabled.” The direct statement was as follows:
“Based on the medical information in our file, your education, and your work experience, you do not meet the definition of Total Disability as defined by the Group policy; we are denying your claim.”
Jajuga was never informed of the denial of his claim for a premium waiver. Prudential also furnished no proof that he had ever received direct notification regarding his denial. Judging from the evidence presented in the case, Jajuga allegedly did not learn about the denial of his claim for a waiver of premiums until seven years after he had submitted it.
Ultimately, Prudential wrote,
“The medical documentation in [the] file does not disclose findings of an impairment or combination of impairments so severe that they would result in the loss of all work capacity for a sedentary position.”
Essentially, Prudential claimed that Jajuga was not totally disabled—despite the extensive medical documentations that Jajuga provided the company. Prudential later went on to say,
“Jajuga does have the ability to sit through an eight-hour day, as long as he is given the opportunity to change positions approximately every one hour with a break for five minutes for standing as needed.”
Prudential relied on its own independent medical examinations and concluded that Jajuga could perform certain gainful jobs based on his prior work experience—and it provided a list: telephone solicitor, automobile locator, customer-complaint clerk, and order taker. Soon after, Jajuga died. The executor, Scibelli (who brought the suit), appealed again. Despite this new information, Prudential maintained its original denial of disability insurance benefits.
The court ultimately found that Jajuga convincingly proved he was “totally disabled” under the terms of the Group Policy. According to Prudential’s language, the court found that Jajuga was “not able to perform work for wage or profit, or do the material and substantial duties of any job for which [he was] reasonably fitted by [his] education, training or experience.”
Prudential even tried to introduce a different defense during the case, arguing that it denied Jajuga because of his alcoholism— Prudential allegedly tried to claim that alcoholism was Jajuga’s primary disability and not the back pain he claimed. The court shot down the argument as well, stating:
“At no point in the administrative appeals process did Prudential assert that Jajuga stopped working because of alcoholism rather than back pain. Of the three denial letters Prudential issued during the appeals process, only the second, dated October 28, 2008, even mentions his admission to the Valley Hospital for detoxification, and that denial letter states that Jajuga stopped working ‘due to back pain and depression.’ Moreover, no evidence in the record—including the Valley Hospital records and the reviews of the administrative record by the outside physicians retained by Prudential—supports the assertion Prudential now makes that Jajuga stopped working due to alcoholism rather than back pain.”
The court even looked to Prudential’s own definitions of totally disabled, to ultimately find the company liable for wrongdoing here and wrote,
“We reject its argument that the eligibility standards in the Group Policy and the Individual Policy substantially differ. The definition of ‘total disability’ in the Group Policy is substantively indistinguishable from the definition of ‘totally disabled’ in the Individual Policy. The Group Policy defines ‘total disability’ as the inability ‘to perform for wage or profit, the material and substantial duties of any job.’ The Individual Policy’s definition of ‘totally disabled’ is the inability to ‘do any gainful work.’ …Indeed, ironically, Prudential’s November 29, 1999, initial denial letter…referred to total disability under the Group Policy as an inability to engage in a ‘gainful occupation.’ The determination of disability under the Individual Policy by Prudential itself is relevant evidence supporting the plaintiffs’ claim that Jajuga was ‘totally disabled’ on May 6, 1997, under the terms of the Group Policy.
Ultimately, the court ruled for Scibelli (Jajuga) on all counts, holding that—based on the evidence—Jajuga was “totally disabled” under the terms of the Group Policy when he stopped working on May 6, 1997.
Frequently Asked Questions About Prudential Claim Denials
What type of compensation is available in an insurance bad faith claim?
In cases where a policyholder has been unreasonably denied benefits, they can seek up to two times the amount of the unreasonably denied claim. Additionally, they can seek compensation for attorney’s fees, interest from the time the claim was wrongfully denied, and non-economic damages for the negative impact that the denial had on the claimant’s credit and emotional distress.
How long do I have to file an insurance bad faith claim against Prudential?
Generally, the statute of limitations in bad faith insurance cases is two years from the date the bad faith conduct occurred. However, this can be confusing to determine. If you believe that Prudential’s denial of your disability claim constituted bad faith conduct, it is important for you to speak to an experienced attorney about the issue as soon as possible in order for them to begin working on your claim and ensure that it is filed before the statute of limitations expires.
How do I appeal Prudential’s denial of my claim?
When you receive your denial letter, it is important to read it carefully as it contains information on how to appeal. This information includes the deadline of when you should appeal the decision. Generally, the deadline to appeal is 180 days after receiving your claim denial. If you miss the 180-day appeal window, you will lose your right to appeal in most cases.
Your attorney will assist you in gathering the evidence needed for the appeal. You want to make sure you are as thorough as possible in showing that you were wrongfully denied the benefits you were entitled to receive.
Some of this evidence can include:
- Additional medical exams to confirm your disability.
- Reports from your treating physician that can better show the full extent of your disability.
- Opinions from vocational experts stating that you are unable to fulfill the duties of your job as a result of your disability.
- Testimony from family members and friends as to how your disability has impacted your life.
You must introduce this documentation into the record regarding your claim, as it may be your last chance. Occasionally, claimants are granted a second right to appeal. However, many times, your next stop after the appeal is court.
Can Prudential deny me for having a pre-existing condition?
Yes. Prudential can deny your disability claim as a result of a pre-existing condition. You must disclose any pre-existing conditions when you obtain your policy. Typically, pre-existing conditions are excluded from the coverage of any disability claims impacting the part of the body where the condition exists. Additionally, if you have filed a claim for benefits, the insurer will generally look back at the past 90 days of your medical record to see if you have obtained treatment for this condition. Sometimes, the look-back period is extended to six months.
How Do I Afford a Top-Rated Bad Faith Disability Insurance Lawyer or ERISA Attorney?
At DarrasLaw, we take all of the disability insurance claim denial cases that we choose to represent on a contingent fee basis. This means that you do not pay us up front. We do not collect fees, unless we get results.
We cover all up-front costs associated with your case—including medical evaluations and investigations. We hope to help as many disabled people from all across America as we can. This contingent fee arrangement helps us ensure more people who need an experienced disability insurance lawyer, or ERISA attorney, can get one.
Has Prudential Denied Your Disability Claim? Contact DarrasLaw Today!
You may have purchased individual or group disability insurance “just in case” you needed it one day. If your “just in case” is now here, and Prudential is wrongfully delaying or denying your claim for disability insurance benefits, contact DarrasLaw today. Our top-rated disability insurance attorneys and ERISA lawyers help people from all across the United States who were denied disability benefits by Prudential.
DarrasLaw is a nationally recognized Top Disability Law Firm. We are fully committed to our mission: to serve the disadvantaged and disabled by ensuring they receive what their insurance companies rightfully owe them. Our seasoned and compassionate bad faith disability insurance attorneys and ERISA lawyers have the skill and experience to take on large insurers at the negotiating table and, if necessary beat them in the courtroom.
Review: 5/5 – ★ ★ ★ ★ ★
“Dear Mr. Darras: I wanted to write this letter to personally say thank you for your representation and settlement of my recent case with Prudential Insurance. Your team of professionals have been at all times respectful, responsive to my inquiries, and most recently, compassionate in regards to the recent news of my father. I have either personally spoken to or by email Heather, Socorro, Catherine, and Jo-Ann. Their attitude and professionalism not only says so much about them individually, but also about DarrasLaw. I spent almost 20 years in the corporate world and personally ran a staff of 30 people. I know that when your staff is happy and believes in the person they work for it’s transferred to every client they touch. These last years have been a very difficult transition for me. All my life, I had been very active living it. I stood out in my work, always noticed and recognized. I stood out in my community whether it be in developing business skills or just loving those children who didn’t have parents. Beyond the physical impairments, the deterioration of my cognitive abilities has been the hardest to deal with. Life with fibromyalgia is not easy, as even today, this letter took the help of my husband, who helped me formulate my thoughts into a coherent and concise statement. Most importantly I wanted to write to you about Heather who, as you know, held my hand and walked with me through this. Heather’s kindness, compassion and respect for me as a person is what helped me withstand this long, arduous process. She kept me updated on all news and responses from Prudential, all the while re-affirming her belief in me. She understood on those dates that she talked with me when I may not have been clear-minded and able to express myself. She always made sure I understood the details and took extra time to explain what would be needed. She always represented herself and you in a professional manner, but never forgot the emotional element of my case. I always believed from day one that Heather was upfront about the possible outcomes of my case, both good and bad. She built an immediate trust between us, and was knowledgeable about my case, and cases like this. Each time she called me, she was updating me – I did not have to update her. With DarrasLaw, I never felt like a number, or just another case. Although I would hope that no one I know would ever need help in a case like mine, I want you to know that I would recommend you and your staff without hesitation. Thank you again for the difference you made in my life. My Sincere Appreciation”
– Carolyn B.
Trial lawyer Frank N. Darras and his team handle a wide spectrum of long-term disability insurance claim denials and ERISA cases from a few thousand dollars to claims worth millions. We have an unmatched track record of forcing big-dog insurers, like Prudential, to fulfill their contractual obligations.
Our nationally renowned disability insurance lawyers and ERISA attorneys handle Prudential insurance claim denials throughout the United States. Call us at (800) 458-4577 for a free consultation, including a free policy analysis.