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PRUDENTIAL ABUSED ITS DISCRETION IN DENYING CLAIM FOR LONG TERM DISABILITY BENEFITS

Thursday, November 1st, 2012

A Federal Judge has determined that Prudential abused its discretion in denying the long term disability insurance claim of a claimant with numerous orthopedic injuries. The long term disability insurance claim had not been approved, on the basis the claimant failed to provide records demonstrating restrictions or limitations in her ability to work. On appeal, the claimant submitted medical support including an articulation of restrictions and limitations; however, Prudential’s hired doctor, who performed only a paper review of the medicals, determined that some limitations were supported, but were not significant enough to impair the claimant from full time sedentary work.

The claimant provided additional medical support, and on her second appeal, Prudential conducted both a paper review and an examination (with a well known insurer friendly doctor), and based upon these reports, reversed its decision and paid benefits. Shortly thereafter, Prudential again terminated the claim, and upheld this determination throughout the appeal process.

In reviewing the record, the Court determined that the claimant was disabled from her own occupation and that Prudential failed to properly account for her occupational requirements — but could not reach a determination as to whether the any occupation claim could be decided, as Prudential had not reached that determination.

The Court thus remanded the claim back to Prudential to first determine whether benefits would be payable for the any occupation claim.

Shelton v. Prudential

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