A Federal Judge in Louisiana has determined that Prudential’s claim determination, to terminate long term disability benefits that had been payable for several years, did not have a rational connection to the facts, and has reinstated the claim and awarded attorneys fees.
The claimant, who suffered from orthopedic injuries following a slip and fall down stairs, had several surgeries, and enjoyed the support for her claim from numerous treating doctors.
Despite the fact that the claimant secured Social Security Disability insurance benefits, Prudential terminated the claim alleging that she no longer had support for her ongoing impairment. Prudential chose an adversarial posture with the claimant throughout the appeal process, and ultimately, simply adopted the opinion of a paper reviewing, non-examining physician. Prudential relied upon well known insurance pandering entities, including Reliable Review Services (RRS) and Dr. Richard Kaplan, a doctor who markets himself to insurers, for the claim review.
The Court was troubled by Prudential’s wholesale adoption of the non-examining physician’s opinion, to the complete exclusion of the support from claimant’s treating providers. Based upon this, the Court determined that Prudential abused its discretion.
Tesch v. Prudential Ins. Co.