In the ongoing case of Andrew Cherry v. Prudential Insurance Company of America, Roy Law Group won a rare but major motion on behalf of our client. The ruling will allow for additional investigation into the wrongful denial of a long-term disability claim as well as breach of fiduciary duty by Prudential.

Why is this win so significant? It has to do with the strict requirements for long-term disability plans that are governed by ERISA (i.e. the Employee Retirement Income Security Act of 1974).

In ERISA cases, it’s not at all typical for additional investigation to be allowed after the deadline for submitting evidence has passed.

Here’s a bit more about the significance of ERISA in cases like this, and why this win, in particular, is such a big deal.

What to know about ERISA appeals

First, it’s important to understand a bit more about ERISA law and how it can impact your claim.

ERISA is a federal law that outlines specific requirements for employers and insurance companies to follow in order to protect employees. If your employer sponsors your insurance plan, then that plan is likely governed by ERISA. This means the rules of ERISA will apply in the event of a dispute over most employee benefits.

Insurance policies like Andrew’s that are governed by ERISA law are extremely complicated.

Insurance policies like Andrew’s that are governed by ERISA law are extremely complicated. The process to file a claim or appeal involves close attention to detail and adherence to strict deadlines that are easy to miss.

In almost every ERISA case, if you don’t submit all of the necessary documents and evidence to support your case by the required deadline, then you’re simply out of luck.

However, this recent ruling by the court of the Western District of Washington in Cherry v. Prudential was a major exception to this rule. Now our team of lawyers at Roy Law Group can gather additional evidence, conduct interviews, and explore any potential bias in the denial of the claim.

This will allow us to build an even stronger case against the insurance company and prove that it actively looked for ways to deny Andrew’s disability claim.

An approval followed by denial

Andrew Cherry, a Software Design Engineer for Microsoft Corporation in Seattle, filed a long-term disability claim due to a severe back condition from a sports injury that progressed.

Like so many disability claimants, Andrew was awarded benefits for a limited period of time, but then Prudential later denied his claim and cut off his much-needed benefits.

Andrew submitted an appeal of the denied claim, along with the results of a Functional Capacity Evaluation (FCE), which concluded that he “exhibited an inability to sustain gainful vocational activity on a reasonable-consistent basis.”

Before making a decision, however, Prudential arranged for an Independent Medical Examination (IME) that was conducted by the insurance company’s hired expert. The conclusions of the IME were vastly different than that of the FCE and suggested that Andrew was only impaired as a result of mental illness.

In its denial of Andrew’s appeal, Prudential relied solely on the results of the IME from its own consultant. The results of the FCE were disregarded completely.

A case of two unique claims

Andrew’s case was unique in that it involved the filing of two claims. The first was to recover unpaid long-term disability benefits for his wrongfully denied claim. That was a given. But the second claim was one that is much less common.

The second claim argued that Prudential had breached its fiduciary duties by acting “not as an impartial administrator of the benefits plan but instead actively looking for ways to terminate his claim.”

The truth is insurance companies actively look for ways to deny disability claims all the time.

The truth is insurance companies actively look for ways to deny disability claims all the time. But actually proving this in court can be difficult, if not impossible – especially without the help of an experienced lawyer.

In this case, the actions of those acting on behalf of Prudential were so egregious, we have set out to prove it.

Breach of fiduciary duties

Our second claim alleges that Prudential had breached its fiduciary duties by doing the following (and more):

  • Soliciting medical opinions “from consultants it knows to be biased in favor of disability insurance companies,” particularly during an Independent Medical Evaluation (IME)
  • Acting in bad faith, if not outright malice, toward Andrew, including through the IME consultant
  • Failing to review and consider the report from Andrew’s Functional Capacity Evaluation (FCE)
  • Treating Andrew as an adversary and failing to conduct an adequate investigation when considering his appeal

Prudential’s legal team argued that the claim for breach of fiduciary duty duplicated the claim for wrongful denial of benefits. Fortunately, the District Court disagreed and ruled in our favor.

The District Court granted the motion for both sides to conduct limited discovery, or investigation, regarding the fiduciary breach claim.

This case is still ongoing and there’s no guarantee that additional evidence will be admitted in trial. Nevertheless, this is a major step in the direction of pursuing justice for our client.

Having an expert legal team can make all the difference

Because of the complexities of the ERISA appeal process, winning against an insurance company like Prudential is likely impossible all on your own. Despite the fact that ERISA was meant to protect employees, the strict appeal process, unfortunately, favors employers and insurance companies.

That’s why it’s so critical to not only have the support of an experienced long-term disability lawyer but one who is also an expert in ERISA law.

Roy Law Group can handle all of the details for you. As experts of ERISA law, we know what to look for and how to navigate the rules that are constantly changing. If you’re facing an ERISA appeal, don’t try to tackle it alone. Reach out to us today for a free consultation.