I've had Group LTD insurance thru my employer since 9/08. Work-related health issues began in 2/10 but I continued to work intermittently with ADA accommodations & SPF (FMLA) leave until 11/30/10 when I took a leave of absence without pay or benefits. I filed a claim with Prudential on 1/6.in addition to all the required forms & documents submitted by my employer, PCP & therapist, I faxed them a MOUNTAIN of supporting medical documents verifying I have narcolepsy, sleep apnea, degenerative disk disease, migraines, hypothyroidism, hepatitis C, major depressive disorder & anxiety that prohibits me from working. I faxed various ADA & SPF request forms from my PCP & therapist regarding my limitations & inabilities to perform essential job functions. I also sent my job description marked with how each essential task - line by line, is affected by the symptoms of my conditions & educational materials as back up with how I am personally affected by each symptom - all in agreement with my PCPs & therapists statements & the published medical symptoms. I faxed the results, charts & graphs for 3 overnight sleep studies. I sent a Dept. Of Public Welfare PA1663, Employability Assessment Form that was used to qualify me for medical assistance. On it, my PCP marked "permanently disabled" with my diagnoses & why I am unable to work. I sent months of diagnostic notes from 3 different doctors' office visits all in agreement; my attendance record for 2010 showing the amount of work I missed due to my conditions.
Additionally, the PCP sent everything in my file for the specified period of 5 to present. My therapist sent my entire file with the diagnoses of major depressive disorder & anxiety detailing why I am unable to work. There were CLEARLY sufficient medical documents to support my claim. But Prudential said medical records, medical professional's expert appraisals of my circumstances presented in a clear & direct manner did not justify or support the medical evidence of my claim of disability.in a letter dated 3/25, Prudential's Disability Claims Manager, Kevin Ally said Prudential has "concluded that there is no medical evidence that your functional capacity was limited" Because I frequently received conflicting info from Prudential, I thought surely this was an error. However, Mr. Ally said (both in writing & verbally) the therapist said in her session notes there was "no change, mental status exam was appropriate with no suicidal or violent ideation".in the letter he admitted, "This information is not consistent with information documented by Ms. S on the Health Care Provider Questionnaire” The inconsistency is in Mr. Ally's exposition not Ms. S's statements. Ms. S said the forms she sent had multiple parts on each page of each report. She said Prudential took one phrase from all her paperwork, twisted it & used it out of context. She said at the top of each report the diagnosis was clearly marked, "Major Depressive Disorder & Anxiety." "No change, mental status exam appropriate" means it is appropriate for the diagnosis & there was no improvement! In the letter, Mr. Ally went on to say, "There was no evidence of a change in your behavioral health symptoms [no suicidal or violence ideation??! ], necessitating the need for inpatient hospital admission for further evaluation"!!! I am so offended by this. This is so inflammatory & abusive! Not everyone with mental health issues plans to kill themselves or needs to be hospitalized! For him to classify mental illness in that way is repulsively discriminatory! It should be noted here that depression & anxiety is not the primary diagnosis. These conditions along with the others contribute or worsen narcolepsy's symptoms, especially fatigue and loss of energy. Narcolepsy remains the primary condition that has caused my inability to work.
Mr. Ally also concluded there wasn't any objective medical proof! He said my PCP, Dr. B made a subjective decision based on what I told him not medical tests. How else would my doctor know what I experienced & my difficulties arriving at work timely & the problems with concentration, focus, memory, fatigue or how the disrupted sleep cycles resulted in my nights & days being “ reversed" which caused me to frequently be late for work? If I did not tell him that sometimes I sleep 2-3 hours/night for weeks & then have bursts of sleeping 12,15 & even 18 hours/day, how would he know? There is no test for that! The diagnosis & treatment plan were based on test results & diagnosed by 4 other doctors before being referred back to him. Prudential's Mr. Ally said those tests were done several years ago as if that negated the results. I pointed out narcolepsy is a lifelong condition. It does not go away & there only so many tests that can be done. Mr. Ally indicated that for my doctor's professional assessment to be accurate, he should have performed "repeat sleep study and blood testing"! The 3 overnight sleep study tests & results faxed abundantly confirm an accurate diagnosis! Furthermore, all the attempts to normalize my sleep cycles thru various medications & behavior modifications have failed. There are only a few medications to treat narcolepsy.in the denial letter he went on to say, "We do agree with Dr. B that aerobic activity could benefit you per a progress note from him." And "This type of activity would help you maintain muscle strength/flexibility, help maintain joint mobility/function, help with weight reduction efforts or help prevent further weight gain, help with sleep/rest, and maintain endurance/stamina. This type of activity would be therapeutic for you in the long run." My doctor did not say this! He makes his dictation while still with me in the visitation room! Furthermore, my PCP knows that I have Achilles heel problems, namely a bone spur under the tendon that would require the Achilles tendon to be removed, the bone scraped and then the Achilles tendon would be reattached. This is a long painful procedure. I'm having enough problems with my other conditions to throw this on the stack! It is very dangerous for Mr. Ally to prescribe treatment he thinks agrees with my PCP's statement! Who would be responsible for the damage caused if I follow Mr. Ally's medical advice being that he does not have any medical degree whatsoever?
Another absurd thing Mr. Ally said was having a sedentary job makes me able to perform the essential, substantial job functions! This is contrary to all the medical evidence sent! Actually, a sedentary job is more difficult for me because of my narcolepsy & chronic back pain. Having a sedentary job doesn't lessen memory or concentration problems in processing complex policies, regulations & calculations. I explained I often forget the policy & have to look it up, but I am easily distracted, lose focus & end up researching an unrelated subject. Then I "lose time" & have no idea how long I have spent on something not related to my original inquiry.
From all the lawsuits & other complaint websites on the internet, this is clearly a pattern of abuse by Prudential. The reasons for denying me were common to nearly all the complaints! If their decision was subjective, how can all those complaints have the same couple of elements in common? Obviously, they didn't base their denial on actual evidence but rather on some corporate edict to enhance profits dragging out the process as long as possible! Mr. Ally said I could appeal, but he took the evidence that was already provided, searched for a thread, twisted & distorted the information given to make it mean whatever ridiculous thing he imagined! I feel like not only are they throwing out actual documentary evidence, they are saying the medical professionals are incompetent liars who falsified insurance & multiple other legal documents! How dare they question these professional's integrity! I am offended & appalled by the blatant discriminatory stereotype of mental illness depicted by Mr. Ally as necessary for a claim. How could a major company like Prudential condone & endorse this type of hurtful, illogical & inaccurate information to allow any of their employees, let alone one in a management position say such inappropriate things while explaining why my disabilities are not appropriate to receive the compensation due from purchasing the protection the insurance was meant to provide?
I requested copies of all the documents received in addition to all of the policies, procedures & regulations Prudential used to base their erroneous, flippant decision. One final point I think factored into their denial is that I didn't know until I filed a claim that I was entitled to partial payments for any pay period I earned at least 20% less than normal. That means they owe me a retro payment for most of the pay periods from June thru November. From the very beginning, this was discussed with Prudential and multiple requests have been made to correct the inaccuracy of the claim begin date of 11/30/10. They said the reason they requested documents for the specified period of 5/10 to present was so that a claim date beginning 5/17/10 would be part of the verifications necessary for the partial payments to be included. I can see this being the next battle.
I cannot understand how Prudential is able to get away with this. Why has this common practice been allowed to go on so long? Surely this can't be legal. When I told Mr. Ally that it wasn't funny to yank around someone with mental health issues who has nothing to lose, he sent a local police officer to my home and called my PCP saying I was suicidal. Doesn't that very act contradict his assertions? I thanked him for his concern for my well-being.
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