Our client, “Susan” we’ll call her, had worked as a Claims Examiner for years when she suffered an intracerebral hemorrhage, or stroke, leaving her with cognitive deficits. Prudential initially approved her long-term disability benefits because the medical information supported that she could not perform her regular occupation.
She later tried to return to work full time, but she had to stop working again because she could not sustain the demands of her job. She continued to struggle with residual symptoms from the stroke, including memory problems, brain fog, fatigue, dizziness, and pain. She also developed severe left pelvis, hip, back, and leg pain. She required a cane for balance and later a mobility walker.
Prudential Denied the Recurrent LTD Claim
Prudential took the position that the medical records did not support impairment preventing her from performing her regular occupation. Prudential acknowledged limitations and restrictions, but still concluded that those restrictions would not prevent her from performing the material and substantial duties of her regular occupation as a Claims Analyst or Claims Examiner.
Prudential looked at her occupation as mostly sedentary. It concluded she could sit without restriction and that her standing and walking limitations would fit within the occupational demands. It also discounted ongoing cognitive impairment, stating that the records did not show significant altered neurological or persistent cognitive complaints supporting functional impairment.
Prudential Upheld the Denial
During the appeal process, Prudential recognized that our client later received devastating additional diagnoses and treatment. A pathology report confirmed a bone lesion in the left pelvis as grade 2 chondrosarcoma. A brain MRI showed evolution of the prior large right basal ganglia hematoma with blood breakdown products and scarring. She ultimately underwent a radical resection of left pelvis chondrosarcoma by hindquarter amputation, including removal of the left leg, hip, and partial pelvis.
Despite all of that, Prudential continued to deny the LTD claim. Its position was that the cancer diagnosis and major surgery were now disabling. But according to Prudential, the medical records did not support that she was disabled from her regular occupation when she stopped working again before the cancer diagnosis and major surgery. Prudential reasoned that because she was no longer in active employment by the time of the cancer diagnosis and surgery, she was no longer insured when she became disabled.
That denial left our client in a terrible position. She had tried to return to work. She could not sustain it. She was dealing with stroke-related symptoms, severe pain, progressive medical problems, cancer, and eventually the loss of her leg, hip, and part of her pelvis. Yet Prudential continued to insist that the evidence did not support disability during the key timeframe.
Learning Our Client’s Whole Story
In LTD cases, the insurance company often focuses on selected office notes and functional snapshots. That can miss the real picture. Our job was to tell the whole story.
Our client explained that, even before the amputation, her pain, drowsiness, dizziness, memory problems, and fatigue were severe and disabling. She said those symptoms were what led her to stop further attempts to keep working.
She described brain fog, poor memory, severe pain, inability to walk unassisted, and lack of mobility. She explained that those problems made it impossible to focus on tasks or do any job. She also described needing to sit in a recliner throughout the day for back, hip, and leg pain, dizziness, drowsiness, and fatigue, and her medication side effects made matters worse.
She had to lie down completely for hours each day. She slept in a recliner at night. She needed help from her husband with basic activities such as getting dressed, taking medication, and hygiene. This was not a person who could reliably perform full-time claims work requiring focus, attention, pace, persistence, and consistency.
Building the Evidence
We helped build the case with evidence Prudential had not fully credited. Our client gave a sworn statement describing her symptoms, limitations, medications, side effects, daily need to recline and lie down, need for mobility assistance, and need for help with basic personal care. Family members also signed statements confirming that her description was consistent with what they observed.
That evidence mattered because disability claims are not decided by diagnosis alone. A diagnosis explains what is wrong medically. But a long-term disability claim turns on function: what the person can and cannot reliably do, day after day, in a work setting.
The appeal and lawsuit that followed focused on the gap between Prudential’s paper review and our client’s lived reality. Prudential had accepted restrictions and limitations but still concluded she could perform the job. We challenged that conclusion because it did not fairly account for the combination of her impairments: stroke residuals, pain, fatigue, cognitive problems, medication side effects, mobility limitations, need to recline and lie down, and later-confirmed cancer-related progression.
The Timing Issue Mattered
It argued that she was not disabled from her regular occupation when she stopped working the second time, and that the later cancer diagnosis could not revive coverage because she was no longer in active employment at that point.
That made the facts leading up to the cancer diagnosis critically important. Our client’s position was that the disabling symptoms did not suddenly begin on the date of formal diagnosis. The severe left pelvis, hip, back, and leg pain existed before the diagnosis. She had already been unable to sustain work. The later cancer diagnosis and surgery simply explained the seriousness of symptoms that had already been disabling.
That is a common issue in LTD cases. Insurance companies sometimes treat the date of diagnosis as if it is the date disability began. But many serious conditions exist and cause disabling symptoms before the exact diagnosis is finally made.
The Lawsuit was Finally Settled for a confidential Sum as the Scheduled Trial Date Approached
As the trial date neared, the case resolved. Prudential and our client reached a confidential settlement.
A Just Outcome? Not Really
No settlement can restore health. It cannot undo a stroke. It cannot erase cancer, nor restore a lost leg, hip, or pelvis. And it cannot give back the months of stress caused by losing disability income while fighting an insurance company.
But the settlement at least gave our client a measure of financial security and finality after a long, difficult fight.
This case illustrates a recurring problem in long-term disability claims. Insurance companies often deny LTD benefits by focusing narrowly on whether a claimant can theoretically perform a sedentary occupation. But a person’s ability to sit in a chair for part of a day does not mean she can reliably perform full-time work.
Work requires more than sitting. It requires concentration, persistence, pace, attendance, memory, stamina, and the ability to function consistently, not just occasionally. Pain, medication side effects, fatigue, dizziness, brain fog, and the need to recline or lie down can be just as work-preclusive as a lifting restriction.
This case also shows why claimant statements and family witness statements can matter. Medical records are critical, but they do not capture the full daily impact of a disabling condition. A careful appeal and litigation record must explain not only the diagnosis, but the real-world functional limitations caused by the condition.
Victims of Disability Should Not Assume the Insurance Company Has the Final Word
Long-term disability insurers deny legitimate claims every day. But a denial is not always the end. A strong appeal and, when necessary, an ERISA lawsuit can force the insurer to confront the full evidence, the policy language, and the real facts of the claimant’s disability.
We were honored to help our client pursue the benefits she deserved during an extraordinarily difficult time.
Results may vary. Every case is different, and no outcome can be guaranteed.
