A federal Judge has determined that Prudential is required to pay both Short Term Disability and Long Term Disability insurance benefits.
The claimant, who had been employed by Comtech Communications as a Technician, making repairs on satellite communications equipment, had suffered from chronic severe headaches, which compelled him to undergo spinal surgery for treatment. Surgery did not resolve his medical difficulties altogether, and his surgeon expected his symptoms to re-occur. He also began to suffer severe back and arm pain related to his spinal condition.
The claimant was terminated as part of a reduction in force (RIF) in March 2015, after learning of the RIF the day prior. At that time, he spoke with his boss and requested to be permitted to file for disability. When he got terminated, he again requested to file for disability and asked Human Resources for the necessary disability paperwork. He was refused such paperwork, and was escorted from the building.
After filing his claim for disability anyway, Prudential denied the claim on the sole basis that he was not an eligible employee for benefits, as his coverage had terminated PRIOR to his disability. The claimant filed an appeal of this denied claim for Short Term Disability insurance benefits, and also filed a claim for Long Term Disability insurance benefits. Prudential issued a denial of both the appeal for Short Term Disability and the claim for Long Term Disability insurance benefits. The claimant filed a second appeal, which was also denied on the same coverage grounds, without Prudential considering the underlying merits of the medical issues.
After determining that Prudential’s policy did not confer discretion upon its claim determination, and that the case would be decided under the de novo standard of review, the Court determined that the claimant was, in fact, a covered employee and eligible for disability insurance coverage through his employment. The Court rejected Prudential’s argument that the claimant could not be disabled on the date claimed, as he was at work that day. In rejecting this argument, the Court relied upon a body of case law which has recognized that “disability is not disproved by the mere fact that the claimant found a way to continue working.”
Because Prudential decided not to give consideration to the underlying medical merits, the Court deemed Prudential to have “forfeited its ability to assert” that the claimant was not disabled, and was foreclosed from arguing against the medical impairment. The Court thus awarded both Short Term Disability and Long Term Disability insurance benefits to the claimant.
One key takeaway from this case for employees who have been suffering from a medical condition and continuing to work, is that one should pursue their claim for disability prior to losing their coverage, as once an employee is terminated, coverage for disability insurance will typically terminate.
Nieves v. Prudential Ins. Co. of America