McFadden v. Prudential Ins. Co. of America, 2013 WL 1297642 (5th Cir. April 2, 2013)
By J. Guy Martin, III
Recently the United States Court of Appeals for the 5th Circuit, in McFadden v. Prudential Ins. Co. of America, 2013 WL 1297642 (5th Cir. April 2, 2013), reiterated how important it is to obtain an attorney not only when in court but also during the claim appeals process of your short and long term disability claims. Mr. McFadden was on the job repairing a roof when a helicopter flew overhead causing him to fall and sustain numerous injuries. As a result, he made claims with Prudential for short term disability (STD) and long term disability (LTD) benefits but was denied benefits on both claims.
Mr. McFadden, representing himself, attempted to take on the burden of fighting these denials. Unfortunately, this burden appeared to be too great as the Court found that in favor of Prudential on both claims. Specifically, the Court held that Prudential did not abuse its discretion in denying STD benefits because the plan stated that no benefits were payable for injuries caused by a work related accident. As for the LTD claim, the Court found that the denial was supported by “substantial evidence” Prudential obtained during the appeal process supporting its denial. This evidence included: numerous notations by his doctors that his pain and the severity of his conditions may have been exaggerated and that he could actually return to work; findings that there were “no objective signs of physical abnormality, only lack of participation”; doctors’ skepticism over his reported symptoms and pain and their concern over his need for pain medication; and records showing doctor notations of him having “dramatic behavior” inconsistent with their findings.
As this Court has made clear, it is very important to leave no stone unturned during the appeal process because waiting until trial is too late. Having an attorney assist you through the appeals process can help to not only ensure that your file contains all of the records, test results, and information needed to support your claim but also will help clear up any inconsistencies in the records and counter any seemingly harmful evidence that could be used by insurers to support their denial. An attorney will also be able to assist in combatting the potential arguments insurers like to use during the appeal process and prior to a lawsuit ever being filed, which is crucial in ERISA cases.
Obtaining an attorney who regularly deals with the issues and arguments used by insurers is important because countering as many reasons and usual arguments used to deny claims early in the appeal process will drastically improve your chances for success during the appeal process but also in litigation.