What Tactics Do Insurers Use to Deny Claims? A Case Study
Insurance companies utilize a wide array of tactics to deny claims, particularly when there is a lot of money on the line. In this post, we will examine a case where Prudential engaged in multiple tactics to wrongfully deny a claim.
Christopher Chapin was a software engineer diagnosed with several mental health issues, including depressive disorder, other trauma or stressor-related disorder and cognitive disorder. As a result of these conditions, Chapin found himself no longer able to work and filed a disability claim under his policies with Prudential. Below are the several ways Prudential attempted to deny Chapin’s claim.
Ignoring Evidence of Disability
Under Chapin’s policy, he was considered totally disabled if he could no longer do the material and substantial duties of his regular occupation for the first 24 months of his policy. Chapin’s cognitive impairments prevented him from performing his job, due to deficits in psychomotor speed, attention, and immediate and delayed recall—all of which were required to be a successful software engineer. Chapin provided doctors’ statements and medical records and objective testing performed by his psychiatrist in support of his disability. Nevertheless, Prudential argued that Chapin could still work under the terms of his policy, using its own experts to challenge Chapin’s evidence.
Relying on Pure Paper Review
It is common for insurance companies to have their experts conduct a paper review claimant’s medical records, often in an effort to undermine them or provide a different opinion. Chapin’s records were reviewed by two doctors. The first reviewing doctor did not even perform a complete review of the records, as she failed to discuss testing done on Chapin. The second reviewing doctor, a neuropsychologist, dismissed the testing because it was done by a psychiatrist versus a neuropsychologist. The Court found that this questioned the reliability of the doctor’s peer review.
While insurers are not required to conduct independent medical examinations (IMEs) or rely solely on treating providers’ opinions, the Court in this instance found that “Plaintiff’s doctors are more probative and reliable than those contracted by Prudential to conduct paper reviews of medical records.”
Failure to Investigate Plaintiff’s Claims
While claimants hold the burden to prove up entitlement to benefits, the insurance company also has a duty to conduct an adequate investigation. Here, Prudential’s own expert indicated several times that independent testing could confirm or deny the validity of the testing already performed. Chapin’s own psychiatrist also indicated that more complex testing could be done. However, Prudential did not request any additional testing until seven months after the reviewing neuropsychologist conducted his peer review.
The Court held that Prudential cannot “shut [its] eyes to readily available information when the evidence in the record suggests that the information might confirm the beneficiary’s theory of entitlement.”
Ignoring the Opinions of Treating Providers
As touched upon above, Chapin submitted evidence from his treating doctors (PCP and psychiatrist) and his therapist who all concurred that Chapin was suffering from mental illness and was unable to perform the substantial and material duties of his occupation as a software engineer. In fact, one of the reviewing physicians indicated that Chapin’s treating provider should be discounted just because he was the treating doctor. The Court found that “wholesale rejection of a treating doctor’s opinion without reason is unjustifiable”.
Insurers will often conduct surveillance of an insured and take the findings (often including video surveillance) out of context to argue that a claimant is not truly disabled or is malingering. As another example, insurance companies often scour a claimant’s Facebook and other social media pages in order to deny claims.
At one point, Prudential received information that Chapin was participating in physical activities. Prudential jumped on this and alleged that such behavior conflicted with Chapin’s claims that he was unable to work. (In spite of the fact that physical activity is thought to help those with depression). The Court found that “evidence that Plaintiff went skiing, hiking, and went to the gym twice per week is irrelevant to Plaintiff’s claim that he was unable to perform his job duties due to cognitive impairment.”
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is using any of the tactics above to evaluate your claim, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
 Chapin v. Prudential Life Ins. Co. of Amer., No. 2:19-cv-01256 – RAJ, 2021 WL 1090749 (W.D. Wash. March 22, 2021).
 Id. citing Rodgers v. Metropolitan Life Ins. Co., 655 F.Supp.2d 1081, 1087 (N.D. Cal. 2009)