Double Win: Successful Appeal of a Termination of Benefits and a Benefit Calculation, Resulting in Reinstatement and a Higher Monthly Payment

Our Client’s LTD Claim

Our client, “Jen,” was a successful associate at a top-tier venture capital firm. After earning her MBA while working full-time in a different industry, she made an exciting career change into venture capital, landing her dream role and advancing her career.

Unfortunately, Jen suffered a traumatic pelvic injury that led to chronic pelvic pain as well as related, hip, back and radiating leg pain. She was determined to continue working, but her symptoms worsened over time. Extended sitting aggravated her pain, making it difficult to participate in meetings, focus on complex analysis, or produce high-level work. Eventually, Jen was forced to take disability leave.

Her insurer, Prudential, initially approved her long-term disability (LTD) claim. However, during a routine review, Prudential terminated her benefits after receiving a form from her primary doctor, who had checked a box on one form indicating he agreed that Jen could perform a full-time sedentary occupation. This single response, combined with Prudential’s conclusion that there was insufficient objective evidence of persisting pain, became the basis for terminating her benefits.

Our Strategy on Appeal

To challenge the termination, our team at Roberts Disability Law took a comprehensive, evidence-based approach.

• Clarifying medical support

  • We obtained a clarification from Jen’s primary care physician confirming continued support for disability. We also coordinated a detailed letter from Jen’s physical therapist, who had specialized expertise in pelvic dysfunction and provided valuable insight into Jen’s daily limitations and treatment progress. To address medical records referencing occasional hikes and other activities, we assisted Jen in preparing a detailed written statement explaining her symptoms and functional impairments.

• Strengthening the objective evidence

  • Although much of Jen’s condition involved pain that could not be easily quantified, her medical file contained some objective findings supporting disability, for example, physical exam notes documented persistent pain, and an MRI confirmed pudendal neuralgia.

    To augment the record, Jen underwent a Functional Capacity Evaluation (FCE), which objectively measured her difficulties with sitting and standing. We also arranged an independent evaluation with a urogynecologist, who provided expert commentary on the underlying medical causes and the credibility of her reported symptoms.

• Challenging the benefit calculation

  • In addition to appealing the termination of benefits, we filed an appeal challenging Prudential’s calculation of Jen’s monthly benefit. We argued that Prudential had used an incorrect bonus figure when determining her pre-disability earnings. Under the policy’s terms, the correct calculation required using her bonus from the prior year—a figure that more accurately reflected her income.

The Appeal Process and Outcome

During the appeal review, Prudential requested that Jen undergo another in-person Independent Medical Evaluation (IME) with a physician of its choosing. To ensure fairness and transparency, we arranged and advanced the cost for an independent nurse observer to accompany Jen. The nurse audio-recorded the session and took detailed notes.

The IME physician concluded that Jen remained disabled under the policy terms, confirming the conclusions of her treating providers and independent evaluators. Prudential ultimately approved Jen’s appeal, reinstated her benefits, and agreed with our challenge regarding the benefit calculation.

As a result, Prudential not only resumed Jen’s monthly payments but also increased her ongoing benefit amount and issued an additional retroactive payment to correct prior underpayments.

A True Double Victory

Jen’s case highlights the importance of thorough medical documentation, support from treating providers, independent expert evaluations, and careful review of LTD policy provisions and benefit calculations. By addressing both the medical and financial aspects of the claim, our firm achieved a double victory—securing Jen’s rightful benefits and ensuring she received the full amount she’s entitled to.