Opinion ID: 620674
Heading Depth: 2
Heading Rank: 3

Heading: Prudential's administration of the Group Policy claim

Text: On September 10, 1998, MBUSA forwarded Prudential a claim for a waiver of premiums under the Group Policy on behalf of Jajuga. [4] Among the forms sent was Dr. Klein's March 30, 1998, attending physician's statement. Over a year later, on November 29, 1999, Prudential sent a letter stating that it had reviewed Jajuga's claim, but it sent the letter only to MBUSA and not to Jajuga as well, as required by the applicable regulations. The letter to MBUSA purports to state the conditions for qualifying as totally disabled under the Group Policy, but the definition of totally disabled set forth in the letter is worded differently from that in the Group Policy at issue in this case. [5] The letter then states: Based on the medical information in our file, your education and your work experience you do not meet the definition of Total Disability as defined by the Group policy, we are denying your claim. There is no evidence that MBUSA informed Jajuga of the letter or sent him a copy. And there is no evidence that Prudential ever notified Jajuga directly that his claim had been denied. It appears that Jajuga did not learn about the denial of his claim for waiver of premiums under the Group Policy until seven years after he had submitted it. On September 16, 2005, MBUSA sent a letter to Jajuga's attorney in response to the attorney's inquiry into Jajuga's life insurance coverage. MBUSA's letter stated that it had received a letter from Prudential dated November 29, 1999, denying the claim. A February 21, 2006, letter from MBUSA to Jajuga's attorney states that Prudential had recently informed MBUSA that it was unable to provide a copy of any document which shows that Mr. Jajuga was informed by them of his premium waiver denial or of his rights to appeal and that Prudential had agreed to allow Mr. Jajuga to appeal their decision on his premium waiver claim. By this time, it was over eight and a half years after Jajuga had stopped working. MBUSA also stated that Prudential has requested that they be provided with . . . [a] list of physicians. . . who have treated Mr. Jajuga since the inception of his illness and that Prudential has agreed to contact these physician[s] directly instead of having Mr. Jajuga request this information from them. On March 17, 2006, Jajuga's attorney sent Prudential a list of Jajuga's past and current health care providers and five executed copies of Authorization to Release Information forms allowing Prudential to request Jajuga's medical records directly from his providers. Despite this undertaking by Prudential to get medical records directly, no additional information was added to the file about Jajuga's medical examinations and medical records from the period immediately after he left work. On June 14, 2006, Prudential re-opened the claim, and on September 5, 2006, Prudential upheld its decision to deny the claim. The denial letter states that the medical documentation in [the] file does not disclose findings of an impairment or combination of impairments so severe that they would result in the loss of all work capacity for a sedentary position. The denial letter does not mention Dr. Klein's attending physician statements of October 1997 and March 1998, nor does it mention the records of Jajuga's hospitalization in May and June of 1997. Jajuga appealed this determination through his attorney on February 28, 2007. The attorney's letter stated that Jajuga had received both SSDI benefits and a waiver of premiums under Prudential's Individual Policy. The letter requested that Prudential provide Jajuga with copies of the evidence upon which Prudential based its determination that he was entitled to a waiver of premiums under the Individual Policy; copies of the evidence upon which Prudential based its determination that he was not entitled to the waiver under the Group Policy; and the names, addresses, and professional qualifications of the persons who took part in determining that Jajuga was not entitled to the waiver under the Group Policy. Prudential responded on April 17, 2007, stating that the disability definition in the Group Policy differed from that in the Individual Policy and the SSDI statute. Prudential also requested medical records for Jajuga's treatment from May 6, 1997 through March 1998. Prudential did not respond to Jajuga's requests for documents related to the granting of his waiver claim under the Individual Policy or for documents related to the denial of his waiver claim under the Group Policy. Jajuga's attorney responded to the request for medical records by reminding Prudential that Jajuga had already sent it a list of his past physicians and release authorization forms. In reply, Prudential restated its request for medical records, and on October 12, 2007, Jajuga's attorney sent Prudential some medical records relating to Jajuga's treatment from 1998 forward and requested an additional thirty days to send along other medical records the attorney had requested. She also informed Prudential that she was not able to secure copies of all of Jajuga's medical records dating back to 1997 because some of his providers did not retain records for more than seven years. The attorney stated that, by the time Jajuga was made aware in 2006 of the fact that Prudential had denied his claim and would allow him to appeal that decision, many of the relevant records had already been destroyed by the providers. One month later, she sent Prudential the records from Valley Hospital related to Jajuga's hospitalization in May and June of 1997 for detoxification and depression and stated she understood that Prudential was provided with all relevant medical records as part of Jajuga's claim for waivers of premiums under his Individual and Group Policies and that Prudential should still have those records, or at least claim reviewers' synopses of them, on file. No such records were ever provided to Jajuga save for the basic documents we described earlier. On October 28, 2008, Prudential informed Jajuga that it had again affirmed its decision to deny his claim. This second denial letter does discuss the records of Jajuga's hospitalization in May 1997, but it again does not mention Dr. Klein's attending physician statements of October 1997 and March 1998. This second assessment of the claim relied in part on a review of Jajuga's file performed in August 2008 by two outside physicians: a psychiatrist and a physical medicine and rehabilitation specialist. The psychiatrist, Dr. Lichtshein, concluded that Jajuga's history of alcohol abuse in and of itself is not a disabling diagnosis and that he did not have depression sufficient to warrant impairment. The physical medicine and rehabilitation specialist, Dr. Thampi, concluded that while Mr. Jajuga does have evidence supportive of functional impairment from a physical medicine and rehabilitation perspective, as of the date 05/06/97 and forward, he nevertheless does have the ability to sit through an eight-hour day, as long as he is given the opportunity to change positions approximately every one hour with a break for five minutes for standing as needed. Based on these reviews of the medical records available in 2008, Prudential concluded that as of May 6, 1997, Jajuga would have been able to perform the following jobs, based on his education and his history in retail and sales and in automotive service: telephone solicitor, automobile locator, customer-complaint clerk, and order taker. Jajuga died on December 31, 2008, and the executor of his estate appealed again. Prudential denied this third appeal on August 24, 2009. The administrative record contains a supplemental review of Jajuga's file by Dr. Thampi, the physical medicine and rehabilitation specialist, dated August 3, 2009. This second review was based in part on medical records apparently not considered in the first review, including Dr. Klein's October 1997 and March 1998 attending physician statements. Dr. Thampi concluded that the new information did not alter the prior assessment.