Prudential denies disability insurance benefits to an engineer with impairment to his thought processes and executive functioning which decreased his ability to function in his high level occupation as a development engineer.
GREGORY DELL: Hi, I’m Greg Dell here with attorney Cesar Gavidia. And Cesar, this is a case we’re going to discuss that recently just came out of the District of Massachusetts against Prudential. Kind of the typical nonsense that we’ve been seeing with Prudential. But this one was, I found, especially offensive since it deals with cognitive impairments. And cognitive impairments appear to be what we see in a lot of claims. And very significant. So let’s talk a little bit about the facts of this case. And what we can learn from this case to benefit people watching our videos, and clients, and future clients as well.
CESAR GAVIDIA: Yeah, sure. So like you said, we see these types of cognitive cases a lot. And in this particular case, comes out of, as you said, the District of Massachusetts – US District Court in Massachusetts. And involved James [ Ampey ] who was a testing and development engineer for MIT Lincoln Laboratories. And he suffered a head injury in 2011. And had some decline in performance over time and taken some FMLA leave. And then in 2014, after a bad performance review, he was kind of influenced to file for disability, which he did with their disability insurer Prudential.
After filing with Prudential, they came back and declined the claim. He was claiming that he had cognitive deficiencies, cognitive decline, problems in his thought processes and executive functioning that impaired basically his ability to function in his high level occupation as a development engineer.
GREGORY DELL: And we often see just looking at the background in 2011 that clients call us and say, look, I’ve been trying to work through this issue for a couple of years. And now I’m getting bad reviews. Or my employer is kind of sticking with me, but they know about it. But often we’ll see the carrier say, well, you worked with it for so many years. What got so bad? So just good to see the facts here that someone said, hey, I worked through it for.
CESAR GAVIDIA: You’re exactly right. And I often tell my clients, and they get concerned. Oh, I was off and on work. And I say, it actually shows that you’re very credible in the sense that you’ve tried to work. You’ve tried to push through it. And ultimately, it began to impact your performance at work to where your employee even started to notice. And they’re recommending that you file for disability. That’s what this disability insurance is for. That’s why they have it.
GREGORY DELL: Right. So that’s what this guy did.
CESAR GAVIDIA: That’s exactly what he did. In the case of Mr. [ Ampey, ] Prudential declined the claim. And claimed essentially that he’s claiming these cognitive deficiencies – these executive function problems. But there’s really no testing in the medical evidence that he submitted, in the medical records, that shows that his complaints are valid. OK. So what he did basically at the suggestion of Prudential was he went out and obtained a neuropsychological examination.
It’s interesting that Prudential actually didn’t submit him for one because we’ve often seen that. They usually hire some third party vendor to find a neuropsychologist whose insurance company friendly. And they send them to one. But he went out and obtained a neuropsychological exam on his own with validity testing. When he submitted it back to Prudential, they submitted it to their doctor who reviewed the testing results. And he says, oh, well, although it had validity testing, the science in the testing was outdated based on current protocol – based on the current literature.
So it’s what we often see. That whole moving target strategy employed by disability insurers and the experts that they hire. You go out and obtain the evidence that they say you should have, and they just moved the target down the road.
GREGORY DELL: So he got the neuro psych exam. Then he got denied. Then he did an appeal. And then what happened?
CESAR GAVIDIA: So they declined it again. And after that, they filed suit in federal court. And the federal court awarded Mr. Ampey his disability benefits. Found against Prudential on the basis that they had won skeptical doctor just calling out the results of the neuro psych exam for really no valid reason. There was specialists that he had on his side. His doctors, his treating physicians, all concluded that he has post concussion syndrome. That this was the cause of his disability. But yet, Prudential decided to go with their doctor. Weigh their doctor more favorably than any of his doctors and all the medical evidence. And for that reason, they found against him.
What’s interesting in this case is that against ERISA – the ERISA guidelines and the ERISA rules – they used the same neuropsychologist on both the initial review of the claim and the subsequent appeal. So they didn’t even use a different physician as they’re required to do. Someone who’s separate and apart from the original decision to do the full and fair review so to speak.
GREGORY DELL: Right. And this wasn’t a case that our law firm handled. But we still talk about it because we track every case around the country. We don’t know how much of an impact or if that was argued by the plaintiff’s attorney to say that the claimant had an unreasonable review. But yeah. The law is that they’re supposed to use a different medical professional. Now another thing that I think was key here was that this claimant was approved for social security disability. And I’m not sure how much weight Prudential put into that in reviewing the claim.
CESAR GAVIDIA: Yeah. When I reviewed the case, it was very clear that they did not really give any consideration or weight as is required of the Social Security Administration decision. It’s not very common that you see someone awarded at the initial application. And that’s what was done here by the Social Security Administration. And the court actually had taken issue with the fact that Prudential, unlike the Social Security Administration, did not consider any of his occupational duties. In other words, the restrictions the limitations and how they applied specifically to his occupation as a development engineer.
Social Security Administration did that. So really all they did was they see the opinion coming from their doctor, and they just went with it. They didn’t really give consideration to anything else.
GREGORY DELL: Right. And all their doctor did was try to pick apart the neuro psych report of the claimant, which is kind of crazy. When someone has cognitive impairment, and they’re claiming may be associated depression or anxiety, how they can do that by just looking at the paper but then saying no, everything that doctor said isn’t really true. Or the testing is invalid, so we’re not going to consider it.
CESAR GAVIDIA: And this just goes to show you that an insurance company can basically find any doctor to say absolutely anything about any test or anything that you submit on behalf of your disability insurance claim.
GREGORY DELL: Right. It’s sad. But luckily, they can try to play games and try to strong arm the plaintiff. But at the end of the day, this is a case where the plaintiff prevailed, which is great. If you have a claim with Prudential or any long term disability insurance company, feel free to give Cesar a call or any of our long term disability insurance attorneys. We represent clients all over the country. And we always offer a free immediate phone consultation. We look forward to the opportunity to speak with you.