Why Prudential May Deny a Long-Term Disability Claim?
Facing a long-term disability can be a life-altering experience, affecting your physical health, emotional well-being, and financial stability. When you have a long-term disability insurance policy, you rely on it to provide financial support when you are unable to work. However, insurance companies like Prudential may deny your long-term disability claim for various reasons.
Understanding these reasons can help you navigate the claims process and improve your chances of a successful appeal.
1. Insufficient Medical Evidence
One of the most common reasons for a long-term disability claim denial is insufficient medical evidence. Insurance companies require comprehensive documentation to substantiate your disability and its impact on your ability to work. If the medical records provided are incomplete, unclear, or not compelling enough to demonstrate the severity of your condition, Prudential may deny your claim.
To strengthen your claim, ensure that you provide detailed medical records from all treating physicians, including diagnostic tests, treatment plans, and progress notes. Additionally, obtaining letters from your doctors explaining how your condition affects your daily activities and ability to work can be beneficial.
Prudential has a team of doctors and nurses who review medical evidence. They can be tough to satisfy. Sometimes you need to arrange testing or examinations that are not strictly necessary for treatment solely to satisfy insurance doctors. A specialized ERISA disability law firm can help you anticipate and obtain the evidence most likely to accomplish this objective.
2. Lack of Objective Evidence
Prudential may deny a claim if there is a perceived lack of “objective evidence” supporting your disability. Objective evidence is anything noted or observed by a treating physician that does not rely on your say-so about your symptoms. Abnormalities noted on clinical examinations, blood test results, cardiac or neurological testing, imaging studies, etc. qualify as objective evidence.
While subjective reports of pain and discomfort are important, insurance companies often place greater emphasis on objective findings such as lab tests, imaging studies, and clinical evaluations. Conditions like chronic pain or mental health disorders can be particularly challenging to substantiate objectively.
To address this, work with your healthcare providers to ensure that all relevant tests and evaluations are documented. Functional capacity evaluations (FCEs) and neuropsychological assessments can provide objective measures of your physical and cognitive limitations, strengthening your claim.
3. Non-Compliance with Treatment
Insurance companies expect claimants to follow prescribed treatment plans to manage their conditions. Prudential may deny your claim if there is evidence that you have not adhered to your treatment regimen, such as missing medical appointments, failing to take prescribed medications, or not following through with recommended therapies.
To avoid this issue, make every effort to comply with your treatment plan and keep detailed records of your appointments, medications, and therapies. If you have valid reasons for deviating from the treatment plan, such as side-effects, risks, or ineffective treatments, discuss these with your doctor and document their recommendations.
4. Pre-Existing Conditions
Most Prudential long-term disability policies have exclusions for pre-existing conditions, which are medical conditions that existed before the insurance coverage began. Prudential may deny your claim if they determine that your disability is related
to a pre-existing condition. To mitigate this risk, review your policy carefully to understand its exclusions and limitations. When filing your claim, provide a thorough medical history and be transparent about any pre-existing conditions. If there is any ambiguity, consider seeking a legal opinion to clarify how your policy applies to your situation.
5. Surveillance and Social Media Activity
Insurance companies like Prudential sometimes conduct surveillance or review social media activity to verify the legitimacy of disability claims. If Prudential discovers activities that contradict your reported limitations, such as engaging in physical activities or travel, they may deny your claim on the grounds of misrepresentation or fraud.
To protect yourself, be mindful of your public activities and social media posts. Ensure that your actions and statements consistently reflect your medical condition and limitations. It is also advisable to discuss with your doctor what activities are medically appropriate given your condition.
6. Definition of Disability
Long-term disability policies have specific definitions of what constitutes a disability. These definitions can vary, with some policies requiring that you are unable to perform the duties of your own occupation, while others may require that you are unable to perform any occupation for which you are reasonably suited by education, training, or experience. Prudential may deny your claim if they determine that you do not meet the policy’s definition of disability.
To address this, thoroughly review your policy’s definition of disability and gather evidence that clearly demonstrates how your condition meets these criteria. Occupational assessments and vocational expert evaluations can provide valuable support in aligning your condition with the policy’s definition.
7. Incomplete or Inaccurate Claim Forms
Filing a long-term disability claim involves completing various forms and providing detailed information about your medical condition, work history, and functional limitations. Prudential may deny your claim if the forms are incomplete, inaccurate, or inconsistent with other evidence.
To avoid this, take the time to carefully complete all required forms, ensuring that the information provided is accurate and consistent. It may be helpful to work with a disability attorney or advocate who can assist you in preparing and reviewing your claim documentation.
8. Policy Exclusions and Limitations
Long-term disability policies often contain specific exclusions and limitations that can affect coverage. For example, most Prudential policies limit coverage for mental health conditions to a specific period, typically 24 months. Other policies place similar limits on disabilities based on fatigue or musculoskeletal issues. Prudential may deny your claim if it falls under one of these exclusions or limitations. To address this, review your policy to understand its exclusions and limitations. If your claim is denied based on an exclusion or limitation, consider seeking legal advice to explore your options for appeal or alternate coverage.
9. Lack of Coordination with Other Benefits
Many long-term disability policies require coordination with other benefits, such as Social Security Disability Insurance (SSDI) or workers’ compensation. Prudential may deny your claim if there is a failure to apply for these benefits or if there is an overpayment due to the receipt of other benefits.
To avoid this, ensure that you apply for any other benefits for which you may be eligible and keep Prudential informed of the status of these applications. If you receive benefits from multiple sources, work with Prudential to accurately coordinate these benefits to avoid overpayments or conflicts.
10. Inadequate Documentation of Work Impact
Prudential may deny your claim if there is insufficient documentation of how your disability affects your ability to perform your job. Simply stating that you are unable to work is not enough; you need to provide detailed evidence of how your condition impairs specific job duties and responsibilities.
To strengthen your claim, obtain a detailed job description from your employer and provide evidence of how your condition prevents you from performing these tasks. Statements from your employer, coworkers, or vocational experts can also support your claim by providing third-party validation of your limitations.
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Prudential sometimes takes longer than it should to make a decision, which is a “deemed denial” under ERISA law.
This is an issue that requires specialized knowledge to recognize and act on. The Department of Labor ERISA “full and fair review” claim regulation, 29 C.F.R. § 2560.503-1(f)(3), controls calculation of Prudential’s decision deadlines and extensions of deadlines. Once a claim is filed, every ERISA disability plan insurer must prove that it has followed these timelines and procedures:
- Render a decision within 45 days of receipt of the claim; but
- It can extend up to 30 days, until day 75, only if prior to the 45-day deadline it notifies the claimant in writing of “circumstances beyond its control” preventing a decision; and
- It can extend up to another 30 days, until day 105, only if prior to day 75 it notifies the claimant in writing of “circumstances beyond its control” preventing a decision.
When an insurer misses these deadlines, the current version of ERISA claim regulations authorizes the claimant to file an immediate lawsuit seeking “de novo” judicial review of the benefits claim. Where a fiduciary fails to “strictly adhere” to the procedural requirements of fairness and timeliness, “the claim or appeal is deemed denied on review without the exercise of discretion by an appropriate fiduciary.” 29 C.F.R. § 2560.503-1(l)(2)(i) (emphasis supplied).
In such a lawsuit, courts are routinely holding that an ERISA insurer violating its regulatory duties forfeits “deferential review” in court. This is a significant procedural and substantive advantage for the claimant.
It has been our experience that Prudential often takes longer than it should to decide claims, and often fails to follow regulatory procedure in doing so.
If you feel like Prudential might be taking too long with your claim, call an ERISA speciality law firm for a free consultation. We can quickly assess whether Prudential has violated its duties, and help you understand how to use that as leverage for a favorable outcome.
Conclusion
Dealing with a long-term disability claim denial from Prudential can be overwhelming, but understanding the common reasons for denial can help you take proactive steps to address potential issues and strengthen your claim. By providing comprehensive medical evidence, adhering to treatment plans, understanding your policy, and seeking professional assistance, you can improve your chances of successful appeal and secure the benefits you need to support your financial well-being during this challenging time.
If your claim has been denied, don’t lose hope. Review the denial letter carefully, gather additional evidence, and consider seeking legal advice with the attorneys at Robinson & Warncke today to navigate the appeals process. With persistence and the right support, you can work towards overturning the denial and obtaining the long-term disability benefits you deserve.