Prudential’s Selective Review of Disabled Claimant’s Medical Records held Arbitrary and Capricious

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In a recent case in the Third Circuit, the District Court determined that Prudential’s decision to accept the opinions and conclusions of its experts without explanation was arbitrary and capricious. Ricca v. Prudential Ins. Co. of America, 2010 U.S. Dist. LEXIS 106148 (E.D.Pa. September 30, 2010) The Eastern District of Pa Court found fault with Prudential’s decision to rely entirely on reviews performed by clinicians who had not examined the claimant and selectively consider and credit medical opinions without articulating its thought processes for doing so.

This is particularly applicable where, as here, the evidence it claims to rely on favors its employer and consists of non-treating and nonexamining experts and there is substantial evidence to the contrary. See also Elms v. Prudential Ins. Co. of Am., No. 06-5127, 2008 U.S. Dist. LEXIS 76917, at *18-20 (E.D. Pa. Oct. 2, 2008) (rejecting as a self-serving, selective use of physicians’ reports, Prudential’s almost exclusive reliance on file reviews performed by non-examining physicians as weighed against evidence from doctors who had treated or examined and had concluded the patient was impaired by significant disabilities).

What was interesting about this case is that the District Court focused on Prudential’s failure to discuss, specifically, in its three declination letters, why or how the medical data failed to support an injury or sickness within the Policy’s definition of disability. They noted that the disparity between the voluminous administrative record and the conclusory evaluations of plaintiff’s condition by Prudential’s health experts, made it impossible to review Prudential’s decision because it is unclear whether the evidence of her medical difficulties was credited in whole or in part or not at all — or instead, was simply not considered. Based on this opinion, it appears as if courts are looking for insurance companies to better explain their rationales, and how they weigh the evidence, and not just fall back on “medical records fail to support a disability” argument.
Given the conflicting evidence in the record, Prudential’s decision to accept the opinions and conclusions of its experts without explanation is itself arbitrary and capricious.”

This case was remanded to the administrator for a thorough and careful analysis of all of the evidence, including the rationale for accepting its experts’ opinions in preference to those of plaintiff’s treating and examining health experts. This is the type of claim in our Third Circuit that our firm, Bonny G. Rafel LLC relies on to convince the Courts to reverse a denial based only on a “peer review” rather than an in person, thorough medical examination.