Our Texas client was seriously injured in a motor vehicle accident. The accident left him with a spinal cord injury rendering him paraplegic. After extensive orthopedic surgery, neurosurgery, and extensive rehabilitation, he remained unable to walk without substantial mechanical assistance. He required bilateral mechanical ankle-foot orthotic devices, known as AFOs, strapped to both legs, and a wheeled walker to support his body weight. His doctors explained that his condition was permanent.
Our client had accidental death and dismemberment insurance coverage through his ERISA employee benefits plan with Lockheed Martin insured by Prudential. The plan provided separate dismemberment coverages for “paraplegia” and “total and permanent” disability.
Prudential denied his claim for dismemberment benefits under both the Basic Accidental and Special Accidental coverages on the alleged grounds that neither “paraplegia”, nor “total and permanent” disability were present.
Our client, a true fighter, refused to accept the denial of the benefits for which he had paid the premium for years and now needed. Â
Prudential Policy Language
Prudential’s denial relied on the following policy language, covering the following loss caused by an accident:
“(7) loss due to Quadriplegia [Total Paralysis of all four limbs], Paraplegia [Total Paralysis of both lower limbs] or Hemiplegia [Total Paralysis of both limbs on one side of the body].”
The policy provided the following relevant definitions:
“Paraplegia: The total and permanent Paralysis of both lower limbs”…
“Paralysis: The loss of all practical use of a limb as it relates to the ability to perform the normal functions and activities of everyday living without the use of prosthesis or any other mechanical devices.”
Prudential’s Denial Reasons
Prudential’s denial focused heavily on the conclusion of its reviewing neurologist that our client did not have “total and permanent paralysis” of both lower limbs and was not totally and permanently disabled.
Prudential noted that he had improved after prolonged neuro-rehabilitation. It acknowledged that he still had significant bilateral lower extremity weakness and required bilateral AFOs and a rollator for ambulation. But Prudential concluded that he did not meet the policy’s requirements for total and permanent paralysis and could perform sedentary work.
The Errors of Prudential’s Denial
Prudential’s conclusion missed the key point by ignoring its own policy definitions. The policy did not require the kind of paralysis a layperson might picture when hearing the word “paraplegia.” It did not require the complete inability to move ones legs.
Since the policy specifically defined Paralysis, that is the definition which governed. Using Prudential’s own policy definition for analysis, we get this: Paraplegia: The total and permanent Paralysis [loss of all practical use of a limb as it relates to the ability to perform the normal functions and activities of everyday living, without the use of prosthesis or any other mechanical devices] of both lower limbs.
This was precisely our client’s permanent condition. His physicians agreed that from the time of his accident, “and still presently, [our client] is unable to use either of his lower extremities to ambulate at all [unarguably “the normal functions and activities of everyday living” for the lower limbs], without supporting his weight on a wheeled walker, while at the same time using a mechanical ankle-foot orthotic device (AFO) strapped to each leg.” The physicians also agreed that his current condition would unfortunately not improve.
Both the wheeled walker and the AFOs qualified as “mechanical devices”. The AFOs are hinged at the ankle to allow movement. The position and tension on the ankle hinge are adjusted using the straps that run vertically at the back calf area. The stiff but flexible material forming the hard shell of the device is designed to provide support as well as spring assistance to movement. Thus our client unarguably requires the use of “mechanical devices” to ambulate.Â
To support categorization of the AFOs as “mechanical devices”, we researched and cited medical journal and AFO industry literature. For example, Prashanth R Kubasad et al 2020 J. Phys.: Conf. Ser. 1706 012203 (“Passive AFOs contain mechanical elements to control the relative motion between the shank and foot parts.”). Our client’s AFOs use a hinged articulated joint, spring-flex material, and straps to adjust tension. His required wheeled walker was also a “mechanical device”, as the wheel and axle are the classic simple example of the term.
Thus our client required use of two mechanical devices together to use his lower limbs to perform the normal function of walking.
The Importance of Building Strong Evidence into the Administrative Record with a Focus on the Policy Language
By the time we were retained, Prudential had already denied the claim more than once. Prudential had also stated that the final level of appeal had been exhausted.
However, under US Fifth Circuit ERISA case law, even after an appeal is denied, additional evidence submitted to the insurer by the claimant before filing suit may still become part of the administrative record if submitted in a way that gives the administrator a fair opportunity to consider it. That can be critically important because, in an ERISA lawsuit, the court reviews the claim denial based on the administrative record alone.
Citing US Fifth Circuit case law requiring that Prudential consider our pre-suit evidence, we submitted better evidence in a stronger detailed supplemental evidence package. The submission included a sworn statement from our client, new custom physician notes specifically addressing in detail that was not explained in the raw medical records how our client’s condition met the policy definitions. We supplied medical and industry literature regarding ankle-foot orthoses that explained AFO types and their mechanical-device function. We included photos and video footage of our client using his AFOs and walker. We retained a vocational rehabilitation expert consultant and submitted his report that our client was not reasonably fit for any employment given his age, experience, education, and physical restrictions.Â
The Evidence Also Supported Total and Permanent Disability
The claim was not limited to the paralysis issue alone. We also argued that our client met the policy’s Total and Permanent Disability provision. There were separate additional benefits available if the facts supported coverage under this provision.
Before the accident, our client worked as an aircraft assembler. His work required substantial physical activity, including kneeling, climbing stairs, bending, stooping, working overhead, leaning while working, working with tools, and using harnesses when working at heights.
After the accident, he certainly could not return to that work. He had not worked at any job for wage or profit since the accident. His employer did not accommodate his restrictions in a way that allowed him to return to his pre-accident position.
The vocational evidence by our retained expert addressed the practical reality Prudential’s denial overlooked. This was not merely a question of whether a person with serious lower-extremity impairment might theoretically perform some sedentary job somewhere. The policy required analysis of the actual disability definition, his work history, his education and training, his experience, and whether he was reasonably fitted for other work.
The evidence showed that he was not able to perform the material and substantial duties of his own occupation and was not able to perform the material and substantial duties of other work for which he was reasonably fitted.
 Prudential Reconsidered
After receiving our supplemental submission, Prudential agreed to consider our supplemental evidence package and reconsider its denial. Soon afterward, it approved the claim and paid all benefits plus interest.Â
This Case Illustrates a Recurring Problem in Denied Accidental Death and Dismemberment Insurance Claims – Misinterpreted Policy Provisions, and Weak Evidence
Insurance companies often deny accidental death and dismemberment insurance claims by misapplying their own policy language. Here, Prudential’s denial did not properly apply the policy’s own definition of Paralysis to the facts. Additionally, the evidence presented to Prudential before submission of our supplemental evidence package was not as strong as it could have been.
Because he was willing to fight “big insurance”, rather than giving up, our client obtained the benefits he paid for and deserved after a life-changing injury. We were honored to be trusted to help.
Results may vary. Every case is different, and no outcome can be guaranteed.
