LOUISIANA
Our client, a Texas ER physician, fought to continue working as long as he could after major cervical and thoracic spine issues that ultimately required the fusion of levels C2–T3 vertebrae. His job duties in the ER required quick thinking and rigorous physical action, performing orthopedic dislocation reductions, intubation, and lumbar punctures as well as placing central lines. He also regularly encountered combative, intoxicated, and drug-altered patients. His post-laminectomy syndrome pain and medication regimen took their toll. He began to falter physically and mentally until it became impossible for him to perform his job safely. Unrepresented, he filed for long-term disability insurance benefits with Prudential after years of premium payments. He explained to Prudential that his pain and increasingly limited mobility endangered his patients. His treating surgeon said he had become “increasingly reliant on a chronic pain regimen including opioids and other controlled substances to function in even the most basic manner” and suffered slow, clouded, and unreliable thinking. He figured there was no way in the world he’d be denied. Everything he submitted was the absolute truth. Prudential Would Would You Want an ER Physician on Opioids in Charge of Your Family?
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But most important and most pertinent to the impact of the administrative appeal, the federal judge in an ERISA case cannot consider any evidence that was not made part of the administrative record during the administrative appeal process before the suit is filed. This means the administrative appeal is your only chance to gather, create, and build the best evidence to support your case later in court. The evidence you submit during the administrative appeal process becomes part of that record that the court can later consider. Whatever case you build (or don’t) is carved in stone before you ever file suit. The insurance companies and their attorneys know this. So they load the administrative record with evidence and reports of their own consulting “experts” favorable to their position in denying the claim. Most claimants and attorneys don’t know this and file “administrative appeals” without supporting evidence beyond medical records. Filing an administrative appeal this way does nothing to help the claim, and it’s precisely what the insurance company hopes a claimant will do. If the insurer denies the claim again, it wastes the claimant’s best and only opportunity to build the best case for reversal, either on administrative appeal or in court. So, build that appeal record like it’s your only chance — because it is. And as always, feel free to give us a call if you need a little help!
Prudential had its physician review his medical records. Without bothering to meet with our client, Prudential’s physician decided that he could continue his full-time duties as an ER physician. Prudential credited its record reviewer’s opinions over our client and his treating providers’ opinions, denying the claim. We filed his ERISA-mandated pre-litigation appeal, loading the administrative record with better objective and opinion evidence of his disability. We also included a more detailed sworn testimony from our client, explaining exactly how his restrictions would endanger patients under different scenarios. Prudential reversed its denial, and they will now pay our client monthly through retirement age. Unfortunately, this case is nothing new. When insurers like Prudential deny long-term disability claims, they hope their insured will “appeal” by arguing disagreement with the denial. They know ERISA law prohibits the court from considering any evidence not submitted with the appeal before filing suit (most people don’t realize this until it’s too late). Loading the administrative record with the best evidence before filing a lawsuit is critical to getting claim denials like these reversed.
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