District Court Overturns Prudential’s Denial of Long-Term Disability Benefits under Employer Plan Based on Well-Documented Evidence from Treating Providers Supporting Total Disability

In Przybyla v. The Prudential Insurance Company of America, No. 3:24-CV-01090-JSC, 2025 WL 28446 (N.D. Cal. Jan. 3, 2025), on Rule 52 cross-motions for judgment, California Northern District Judge Jacqueline Scott Corley granted judgment in favor of Plaintiff finding that she had satisfied her burden of demonstrating “total disability” under her employer-sponsored ERISA long-term disability (“LTD”) Plan.

Plaintiff worked as an Engineering Coordinator-New Business for her employer, California Water Service Company. She stopped working and sought LTD through her employer-sponsored plan insured by Prudential. Plaintiff asserted that her health conditions, including fibromyalgia, cervical stenosis, migraines, and vestibular issues, rendered her incapable of performing her occupational duties with reasonable continuity, despite her substantial efforts to manage her symptoms through consistent medical treatment and physical therapy. Prudential denied her claim and upheld its decision on two subsequent appeals. Prudential’s denials were based primarily on their own medical reviewers’ opinions, who argued that the medical records did not substantiate the severity of her reported symptoms.

On de novo review, Judge Jacqueline Scott Corley meticulously examined the administrative record and the persuasiveness of the conflicting medical opinions. The Court concluded that Plaintiff had sufficiently demonstrated that her symptoms rendered her unable to perform her occupational duties under the terms of the LTD plan as of May 11, 2022. Key to the decision were the consistent and detailed medical records from Plaintiff’s treating physicians, who documented her ongoing struggles with fibromyalgia, cervical stenosis, and related conditions. The ruling emphasized the credibility of Plaintiff’s consistent symptom reports, her diligent pursuit of medical treatment, and the corroborative testimonies of her treating providers.

The Court found the medical reviews of Prudential’s appointed physicians were less persuasive, emphasizing that the reviewers did not personally evaluate Plaintiff, and relied solely on a review of Plaintiff’s records which undermined their conclusions. The Court further criticized Prudential’s reliance on a lack of objective findings, noting that conditions like fibromyalgia often do not present with clear-cut objective evidence. The Court reinforced that subjective symptoms, when well-documented and consistent, can suffice to establish disability under an ERISA LTD Plan. The decision also highlights the importance of comprehensive medical documentation and the valuable insights of treating physicians, who are often best positioned to assess the impact of a patient’s symptoms on their ability to work.

This case underscores the importance of comprehensive medical documentation and the valuable insights of treating physicians, who are often best positioned to assess the impact of a patient’s symptoms on their ability to work. It also highlights the challenges claimants face when insurers rely solely on record reviews without personal evaluations. The court’s decision not only grants Przybyla the benefits she sought but also sets a precedent for evaluating similar disability claims with complex, chronic conditions.

If Prudential or your insurer has denied or otherwise limited your disability insurance claim, contact us for assistance.