Did Your Long Term Disability Insurance Company Give Little, if Any, Consideration To Your Medical Records? Court Reprimands Prudential Insurance LTD For Conclusory Disability Claim Evaluation and Denial

Jim Ampe fell and struck his head in the bathroom of his home in August 2011. Following the accident, Jim complained of cognitive fatigue, difficulty concentrating, and the inability to focus in a noisy environment. Jim underwent a Neuropsychiatric evaluation in the fall of 2012 which found a significant decline in Jim’s physical, cognitive and emotional behavior which was consistent with what is often seen in post-concussive syndrome. Notwithstanding his post-concussive syndrome, Jim continues to work but took intermittent FMLA leave over the next few years from his employer. His annual performance reviews, however, worsened significantly over time. Following Jim’s 2014 performance review, which was worse than he had ever received, his employer informed him that they would not provide any further workplace and recommended he apply for long-term disability benefits. Jim applied for long-term disability benefits with the Prudential Insurance Company in early February 2015.

In support of his claim Jim submitted all of his medical records which showed that he had suffered a traumatic brain injury in 2011 and according to his Doctor “Jim continued to be limited by post brain injury symptoms especially dizziness, fatigue, headache, nausea, confusion and irritability. He’s not able to tolerate work in 32 hours or more of work is not medically feasible.“  Jim’s doctor also opined that up to 5 to 15% of people who suffer concussions continue to suffer persistent post concussive symptoms. Jim also submitted the 2012 neuropsychiatric evaluation that exhibited cognitive decline.

Shortly after the submission of the claim, Prudential’s Vice President and Medical Director, Dr. Rajesh Wadhwa, quickly dismissed all of the medical information and faulted the 2012 neuropsychiatric testing  for failing to perform validity testing.  Jim’s disability claim was denied on May 11, 2015. On October 18, 2015 the Social Security administration approved Jim for the award of Social Security Disability benefits. Jim submitted a second appeal with another neuropsychiatric evaluation. His long term disability claim appeal was again summarily denied based on a cursory review of the medical records performed by Dr. Kristin Fiano.

Jim sued Prudential and a Federal Court Judge reversed the denial of long term disability benefits and ordered Prudential to re-evaluate Jim’s claim. In reviewing the Prudential disability claim evaluation the Court wrote:

“What concerns the court in this case is the appearance that Prudential gave conclusive weight to Dr. Fiano’s opinions based on her file review without giving any substantive consideration to the records and opinions of Ampe’s treating physician and the doctors who had examined Ampe to evaluate his neuropsychological symptoms. In its final denial letter, Prudential made several conclusory statements that appear unanchored in the medical records. Prudential, for example, criticized Dr. Bekken’s validity testing despite her careful explanation of why the testing convinced her that Ampe was not malingering. The reference to somatization is also troubling. Somatization (also known as Briquet’s syndrome) is a discredited clinical diagnosis, derived from the theory that acute anxiety or stress can precipitate real or, more often, imagined physical symptoms in a patient. The reference to somatization underscores the extent to which Prudential’s decision relied on Dr. Fiano’s personal skepticism regarding the validity of any diagnosis of post-concussion syndrome, and on her apparent, if not overtly stated, conviction that Ampe was a malingerer. While the court is not in a position to address in any definitive fashion the medical validity of post-concussion syndrome as a diagnosis, there is enough support in the medical literature documenting its existence so as to make a denial of LTD benefits based on one skeptical doctor’s file review open to question, especially where three examining specialists and a treating physician at different times came to a contrary conclusion.”

The Court was also highly critical of the failure of the Prudential’s long term disability claim analysis to properly consider even its own concession that Jim’s cognitive functioning was not optimal. To that end, the Court wrote:

A second, and perhaps more critical deficiency in Prudential’s benefit denial was its failure to analyze Ampe’s conceded limitations against the demands of his occupation as an electrical engineer. A benefits determination is not “‘reasoned’ when the [claims] administrator sidesteps the central inquiry … [of] whether the claimant [is] … able to perform the material duties of [his] own occupation.” McDonough v. Aetna Life Ins. Co., 783 F.3d 374, 380 (1st Cir. 2015). Plan administrators may not dismiss evidence merely because it is subjective, but must meaningfully address why reported symptoms are either false or exaggerated or do not impede a claimant’s ability to work. Miles v. Principal Life Ins. Co., 720 F.3d 472, 487 (2d Cir. 2013); see also Love v. Nat’l City Corp. Welfare Benefits Plan, 574 F.3d 392, 396 (7th Cir.2009) (finding that defendant failed to sufficiently explain the reasons for its denial of disability benefits as required by 29 U.S.C. § 1133, where “neither the initial termination letter nor the subsequent letter denying [the claimant’s] appeal explained why the reviewer chose to discredit the evaluations and conclusions of [the claimant’s] treating physicians”). In this context, Prudential failed to meaningfully address and properly weigh Ampe’s complaints of severe headaches and fatigue. As underscored by Judge Selya in McDonough v. Aetna Life Ins. Co., 783 F.3d 374, 380 (1st Cir. 2015), “medical evidence is only part of the equation. To assess a claimant’s ability to perform his own occupation, a decisionmaker must be aware of, and apply, the requirements of the occupation.” Here, there is no record evidence that Prudential (unlike the SSA) engaged in an analysis of the impact of Ampe’s limitations, whether subjective or substantiated by the clinical examinations and objective testing, on his ability to perform the work of a Senior Development and Test Engineer.9 See Miller v. Am. Airlines, Inc., 632 F.3d 837, 854 (3d Cir. 2010) (citing Elliot v. Metro. Life Ins. Co., 473 F.3d 613, 619 (6th Cir. 2006) (finding a decision could not be considered “reasoned” where there was no discussion of claimant’s duties or her ability to complete them in light of the various diagnoses).

If you or a loved one has suffered from a traumatic brain injury, or if you need representation after your insurance company gives little consideration to your medical records, you need to speak with a Massachusetts insurance claims attorney at The Law Offices of George M. Thompson today.

JAMES AMPE V. THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, ET AL.