Sun Life Pays Disability Benefits For Three Years To A Claimant Who Wasn't Actually Covered Under A Sun Life Policy

In the case of Pamela P. v. Sun Life and Health Insurance Company, the court record shows that Pamela P. applied for long-term disability benefits under an employee benefits plan that was maintained by Los Padres Bank for its employees and was awarded disability benefits for over three years. Said plan was underwritten by Sun Life with its Group Certificate governed by ERISA (the Employee Retirement Income Security Act). Mention of the certificate is relevant to this proceeding in that the certificate was specifically assigned to Los Padres Bank in October 2001, with its subsidiaries listed as Harrington Bank and Harrington Wealth Management.

Employees included in the Sun Life policy of Los Padres Bank are required by the language in the policy to be “insured under the policy at the time your Disability commences,†in order to be eligible to receive disability benefits, which is the issue that was debated in Pamela P.’s case which was heard in the United States District Court of the Western District of Missouri. In addition, the certificate “grants Sun Life express discretionary authority to approve or deny claims.â€

Background of Pamela P.’s Disability Claim

Pamela P. began working for Los Padres Mortgage Company, LLC in 2002 as vice president and business development officer. At the time of Pamela P.’s employ, Los Padres bank owned 51% of Los Padros Mortgage Company, LLC, and Resource Marketing Group, Inc. owned the remaining 49% of the mortgage company. Pamela P. was paid a monthly salary in addition to commissions in her job there. Reporting to Los Padros Bank, Pamela P. adhered to the bank’s hiring policies and practices and was considered to have a light duty occupation that required some travel.

On February 1, 2004, Pamela P. fractured her right foot when she missed a step while exiting a friend’s home during a Superbowl party. Upon examination by her doctor, Pamela P.’s doctor recommended that Pamela P. undergo an “open reduction of the fracture to straighten out the angulation and to insert a couple of screws to help stabilize the fracture.†Pamela P. was provided with a Cam Walker and told not to bear weight on the ankle and was instructed to use crutches to assist that provision. On February 6, 2004, Pamela P. underwent the procedure and her doctor noted some tissue damage while performing the surgery, telling Pamela P. to stay off the ankle until he instructed her otherwise.

During her follow-up examinations on February 13, and February 23, Pamela P. was said to be healing appropriately. Unfortunately, on February 23, 2004, Pamela P. fell in a restroom at work and re-injured her right foot. Advised to keep the foot elevated and not to drive, Pamela P. was instructed to not return to work until the foot had healed Re-evaluated on March 22, 2004 with some other complications, Pamela P.’s doctor ordered her to remain on a non-weight bearing status. Consequently in April 2004, Pamela P. applied for long term disability benefits with Sun Life and began receiving payments in May 2004 (more info on the disability application).

Pamela P. was examined by her doctor again on April 21, 2004 and he noted that Pamela P. was in pain and was continuing her use of the Cam Walker and a wheel chair. On April 27, 2004, Pamela P.’s doctor saw Pamela P. again as a result of her ongoing pain, noted that her wound was healed and attributed her pain to the Kwires in her foot. He x-rayed the Kwires, which were found to be intact and planed to remove them soon and noted that Pamela P. had “osteroporosis of the fracture area.â€

Continuing follow-up visits with no relief, Pamela P. applied for Social Security Disability (SSD) in August, 2005; and while the Social Security Administration found that Pamela P. was impaired, it suggested she pursue a sedentary position. After extensive therapies, surgical procedures, and pain management, Pamela P.’s doctors determined that she “was able to work in a sedentary work setting†and that “further rehabilitation services†would not improve her situation.

Sun Life Terminates Pamela P.’s Disability Benefits

Upon evaluation of Pamela P.’s file and some video surveillance (read more on video surveillance for disability claimants) that showed Pamela P. moving without assistive devices by an independent medical consultant, Sun Life terminated Pamela P.’s disability benefits in July of 2007. In May 2008, Pamela P. appealed the insurer’s decision to terminate her disability benefits, submitted various supporting documentation of her pain and her “mental cloudiness†from the taking of pain medication. After many exchanges of Pamela P.’s medical records among physicians and administrators, on April 6, 2009, Sun Life upheld their decision to terminate Pamela P.’s disability benefits.

During the shuffling of paperwork and the many evaluations, Sun Life tried one more tactic to deny Pamela P.’s disability benefits that appeared to be a point worth going to court with. In a twelve-page letter explaining the insurer’s denial, it wrote that besides not having sufficient evidence to show a true disability on Pamela P.’s part, that Pamela P. was ineligible for Sun Life disability benefits because Los Padres Mortgage Company was “not a covered subsidiary relative to the coverage issued to Los Padres Bank†in the first place. In addition it noted that Pamela P. did not receive treatment for her ankle from October 2006 through February 2008, causing the recent application for benefits to fall “outside the applicable 6 to 12 months interval†required in Sun Life’s policy with the bank.

Pamela P. and Her Disability Lawyer Head to District Court to Pursue Her Claim

And, while the Court looked at Pamela P.s case and considered her suit, in the end, they had to conclude that Pamela P. was not covered under Sun Life’s policy as Los Padros Mortgage Company LLC was not on the Los Padros Bank’s certificate for disability benefits to employees, making all other arguments null and void. The court stated that “At most, Sun Life should have caught the coverage error sooner, which is not the same thing as misrepresenting a material fact.†Noting that Pamela P. received three years of benefits for which she was not entitled and that a claim for equitable estoppel did not exist, the court ruled in favor of Sun Life and denied Pamela P. further access to any Sun Life disability benefit payments.

Note: Equitable estoppl would exist if Sun Life knew that Pamela P. wasn’t entitled to benefits, but provided those anyway. By continuing to pay those benefits with the knowledge that Pamela P. was ineligible would have obligated the insurer by law to continue paying benefits meaning that the insurer could not arbitrarily discontinue them. Here, though, Sun Life was not purposely misrepresenting a material fact by paying her and case law states that “[c]ourts may apply the doctrine of estoppels in ERISA cases only to interpret ambiguous plan terms.†The plan terms here weren’t ambiguous; Sun Life paid benefits to Pamela P. in error. The court summed it up as follows:

Sun Life’s failure to note the lack of coverage in its initial determination was an error, not an interpretation of an ambiguous provision. Furthermore, ‘common-law estoppels principles cannot be used to obtain ERISA benefits that are not payable under the terms of the ERISA plan.’


Did you find this helpful?
Unhelpful (0)

Resources to Help You Win Disability Benefits

Disability Benefit Denial Options
Submit a Strong Appeal Package

We work with you, your doctors, and other experts to submit a very strong appeal.

Learn more

Sue Your Disability Insurance Company

We have filed thousands of disability denial lawsuits in federal Courts nationwide.

Learn more

Protect Your Benefits
Get Your Disability Application Approved
We help claimants throughout the entire application process.

Learn more

Prevent a Disability Benefit Denial
We manage every aspect of your disability claim following claim approval.

Learn more

Negotiate a Lump-Sum Settlement

Our goal is to negotiate the highest possible buyout of your long-term disability policy.

Learn more

Sun Life Reviews
(642)

Policy Holder Rating

1.5 out of 5
Read 42 reviews
2%would recommend
5
0%
4
0%
3
0%
2
50%
1
50%
Timely Payments
1.8out of 5
Handling Claim
1.9out of 5
Customer Service
1.9out of 5
Dependable
1.8out of 5
Value
1.9out of 5
Showing 8 of 642 Reviews
Sun Life

Unscrupulous Tactics

Reviewed by Misseekayy on December 19th 2023   Verified Policyholder | May 2023 date of disability
Sunlife uses unscrupulous tactics in order to prevent payment of claims. They wait until it is close to the 30 day mark and then they ask for another form of information o... read more >
Sun Life

What a mess

Reviewed by Unknown on September 12th 2023   Verified Policyholder | July 2020 date of disability
This place has no idea what day it even is. First they attach my claim to my previous claim in which was a new claim. They messed up and denied me then made me wait yet ag... read more >
Reply
Sent on September 12th 2023 by Attorney Gregory Dell

I am sorry to hear what you are experiencing. Make sure you deal with Sunlife writing and follow up every day. If you would like assistance please contact us.

Sun Life

They leave you unable to fight

Reviewed by Kara on May 1st 2023   Verified Policyholder | July 2014 date of disability
I received LTD from Sunlife since 2014 until 2021. I still tried fighting in 2022. Somewhere they changed my claim from physical to mental but nothing in my medical histor... read more >
Reply
Sent on May 1st 2023 by Attorney Gregory Dell

Kara:
Thank you for submitting a review about your experience with Sun Life. If you appealed your denial, then you may still have time to file a lawsuit to obtain... read more >

Sun Life

Sun Life is a real pain

Reviewed by Chris K. on May 20th 2022   Verified Policyholder
Sun Life is a real pain. I just want them to buyout my long term disability policy, but they keep playing around and around. I just to be left alone and given my lump sum ... read more >
Reply
Sent on May 20th 2022 by Attorney Rachel Alters

Chris, you can contact me at Rachel@diattorney.com and we can set up a call to discuss your buy out options.

Sun Life

Everytime SunLife receives my information they ask for another 7 to 10 business days

Reviewed by Joe M on May 31st 2021   Verified Policyholder
Told Sunlife I’m getting an attorney since my claim was filed April 16, 2021, still pending a decision and everytime they ask for more information and they receive it, t... read more >
Reply
Sent on May 31st 2021 by Attorney Jay Symonds

Joe, I assume this is a short term disability claim pursuant to a group policy issued to your employer. If so, the relevant federal claims regulations allow the carrier... read more >

Sun Life

I have lost everything due to non payment of my claim.

Reviewed by Lester H. on November 2nd 2020   Verified Policyholder
I have lost everything due to non payment of my claim.
Sun Life

SunLife said if I don't apply for SSI they will lower my payments

Reviewed by Jeffrey R. on July 26th 2020   Verified Policyholder
Sun Life is trying to get me to apply for ssi. Have long term disability though them been on it for 9 months. Live in PA. Telling to apply or they are lowering my payments... read more >
Reply
Sent on July 26th 2020 by Attorney Rachel Alters

Jeffrey, you are required under the policy to apply for Ssdi. If you don’t they will take an estimated offset and decrease you benefit by that amount.

Sun Life

I don't understand SunLife's overpayment letter

Reviewed by Gina L. on July 15th 2020   Verified Policyholder
My name is Gina and I have been collecting LTD from my previous employer through Sun Life for almost 2 years. I am currently easing back into the work force and I work a p... read more >
Reply
Sent on July 15th 2020 by Attorney Rachel Alters

Gina: I suggest you contact our office and speak with one of the attorneys to discuss the specific questions you have. At that point you can send along the letter.

Answered Questions by Our Lawyers
(29)
Showing 8 of 29 Answered Questions

Q: Can SunLife offset dependent social security benefits received on account of my wife's disability?

Answered on May 8th 2020 by Attorney Stephen Jessup
A: Dominick, unfortunately, employer provided disability policies contain language that allows for the offset of ... Read More >

Q: Does SunLife have a required time to make a decision? Can they request medical records that have nothing to do with my illness?

Answered on February 19th 2019 by Attorney Gregory Dell
A: Megan, in an ERISA governed claim Sun Life would have 45 days to make a decision and have the option of taking... Read More >

Q: What happens if a policy doesn't mention something I believe I had and paid for (COLA)?

Answered on July 14th 2018 by Attorney Rachel Alters
A: Rachael, if the policy does not mention a COLA then that usually means that the insurance company does not off... Read More >

Q: Can SunLife deny me on the basis on a preexisting condition?

Answered on June 15th 2018 by Attorney Alex Palamara
A: Scott, the policy governing your claim will define what is a pre-existing condition. If you were having sympto... Read More >

Q: Can I sue SunLife if I signed a Settlement & Release Agreement?

Answered on June 4th 2018 by Attorney Jay Symonds
A: RB, if you signed a Settlement & Release Agreement you are bound by those terms and would have waived your rig... Read More >

Q: Can I still get my short term disability benefits if I'm terminated?

Answered on January 26th 2018 by Attorney Stephen Jessup
A: C. Freeman, even if you are terminated you would still have legal rights under your policies. Your rights unde... Read More >

Q: Can I sue SunLife for pain and suffering?

Answered on January 12th 2018 by Attorney Stephen Jessup
A: Jim, under ERISA governed policies there are no actions for pain and suffering, only unpaid benefits. Read More >
Helpful Videos
(875)
Showing 12 of 875 Videos
Disability Benefit Tips
(330)
Showing 8 of 330 Benefit Tips

Tips for Applying for Sun Life Disability Insurance Benefits

If you're covered by a long term disability policy offered by Canadian-based carrier Sun Life... Read More >

Can a Disability Claimant Refuse to Attend an IME During an Appeal?

The main issue in Stevens v. Sun Life and Health Insurance Company is whether a claimant’s refusal to attend an IME means the administrative... Read More >

Disability Benefit Denial Reason #5 – Your Medical Evidence is Weak

If you're seeking long term disability benefits from an insurance company, you may be concern... Read More >

Disability Benefit Denial Reason #4 - Your Doctor Is Misled By the Disability Company

When you're seeking disability benefits under a long term disability policy, your medical rec... Read More >

Disability Benefit Denial Reason #3 - Video & Social Media Surveillance

One thing many long term disability claimants don't know about (or expect) from the claims re... Read More >

How Do You Fight a Long-Term Disability Denial?

Getting a denial letter from your disability insurance company is one of the ultimate insults... Read More >

Disability Denial Reason #2 - Change of Disability Definition & Vocational Review

One of the top reasons for terminating a claimant's long term disability benefits involves th... Read More >

Disability Denial Reason #1 – Paper Review & IME

At Dell Disability Lawyers, we've seen insurance companies give countless reasons to deny lon... Read More >
Dell Disability Cases
(373)
Showing 8 of 373 Dell Disability Cases

Sun Life Overturns Its Previous Denial of LTD Benefits for Massachusetts Teacher

Our client, Ms. L, formerly worked as a Technology Teacher for a public high school in Massachusetts. For many years Ms. L suffered from chron... Read More >

After Appeal Sun Life Finally Approves Disability Benefits for Data Engineer

Prior to filing for disability, our client was employed as a Manager of Data Engineering Analytics for Avanade. A job he loved and excelled at... Read More >

Sun Life overturned previous denial of LTD for California Diagnostics Manager

Our client, Ms. G, formerly worked as a Diagnostics Manager for a regional Healthcare System. In October 2016 a number of medical issues, incl... Read More >

Unum and Sun Life approve disability benefits to OB/GYN

Our client, a well-established and experienced, OB-GYN, who had run a successful medical practice before becoming part of a hospital system, b... Read More >

After appeal filed by Attorney Jay Symonds, Sun Life overturned its previous denial of long term disability benefits for Florida ICU Nurse

Our client, Ms. A, formerly worked as a Nurse in the Intensive Care Unit. In September 2014 a number of medical issues, including chronic pain... Read More >

Sun Life Approves Disability Benefits to Surgical Services Director

Prior to filing for disability our client worked as a Surgical Services Director for a large hospital system. Her occupation came with an incr... Read More >

Sun Life ignored its own medical expert's opinions supporting registered nurse's inability to work in a sedentary occupation due to severe rheumatoid arthritis

Sun Life reinstated LTD benefits after Dell Disability Lawyers appealed wrongful termination of LTD benefits of registered nurse suffering fro... Read More >

Dell Disability Lawyers convinces Sun Life to Overturn Denial of Long Term Disability Benefits for a Person Suffering from Severe Cervical Disorders

An employee of FLSmidth, Inc. who worked as a Senior Procurement Agent since 2007 was forced to discontinue working in February of 2012 due to... Read More >
Disability Lawsuit Stories
(765)
Showing 8 of 765 Lawsuit Stories

Can Sun Life deduct Veterans' Benefits from a monthly disability insurance benefit payment?

The case of Marco Martinez v. Sun Life Assurance Company of Canada (Sun Life) provides guidance in determining whethe... Read More >

California Court Reverses Sunlife Disability Denial for Woman with Fibromyalgia

In this video, disability insurance attorneys Rachel Alters and Gregory Dell discuss a Califo... Read More >

Court Remands Sun Life to Consider Social Security's Decision to Award Plaintiff Disability Benefits

In Green v. Sun Life Assurance Co., the issue concerned whether or not the claimant was continuously disabled during the 180-day required elim... Read More >

Sun Life's Video Surveillance Backfires & is Ordered to Pay Disability Benefits

In the case of Solnin v. Sun Life and Health Insurance Company, et al., the plaintiff, an assistant bank manager, injured her back at work and... Read More >

Court Rules That Sun Life Did Not Properly Review a Mental Nervous Disability Claim

In this video nationwide disability insurance attorney Stephen Jessup discusses a recent Sun ... Read More >

Criminal-Act exclusion does not apply without sufficient causal nexus

We get many calls involving claims denied based upon exclusions for losses or disabilities resulting from certain excluded conditions. Common ... Read More >

Court Awards Attorney's Fees After Disability Insurance Claim is Remanded Back to Sun Life

When suing an insurance company to recover disability benefits in an ERISA case, the three most likely outcomes by the court are; (1) awarding... Read More >

Accountant Punished by SunLife for Working Part-Time During Tax Season

Most long-term disability policies require a claimant not only be unable to perform the material and substantial duties of his or her occupati... Read More >

Reviews from Our Clients

Request a Free Consultation

Our Lawyers Respond Same Day

5 Ways We Help Get Your Benefits Paid

Get Your Disability Application Approved

Our goal is to get your application for disability income benefits approved. Applying for disability benefits can be a difficult process and the information you provide is critical. Most disability insurance companies look at your application in hopes of finding a reason to deny your claim. Your disability company will ask you to complete numerous forms, interview you, request lots of information, speak with your doctors and possibly request to have you examined by their "hired gun" doctor.

Through our experience of having helped thousands of disability insurance claimants, our lawyers will guide you through the entire application process and give you the best chance to get your disability claim approved the first time.

Submit A Strong Appeal Package

If your disability insurance benefits have been wrongfully denied, then our lawyers know exactly what it takes to get your disability claim approved. You only get once chance to submit an Appeal, therefore every piece of evidence that will support your disability claim must be included. The goal is to win your disability benefits at the Appeal level, but while preparing your Appeal you must consider how a federal judge will review your disability claim if your benefit denial is upheld.

Preparing a strong disability appeal package is an art that requires you to understand how the courts interpret your disability policy language, ERISA regulations / laws, and how to strategically present evidence in support of your definition of "disability". We encourage you to contact any of our lawyers for a free immediate review of your disability denial.

Sue Your Disability Company

98% of the disability insurance lawsuits filed by our law firm have resulted in either the payment of benefits or a lump-sum settlement agreement. Our disability lawyers have filed ERISA governed and private policy long term disability insurance lawsuits against every major disability insurance company in state and federal courts nationwide and we love fighting for the "little guy" against the multi-billion dollar insurance company giants.

We have recovered hundreds of millions of dollars for our clients and we would like the opportunity to provide you with a free review of your disability benefit denial. There are many complex factors in a disability benefit lawsuit and the legal battle to win long term disability benefits can be fierce.

Prevent A Disability Benefit Denial

Approval of long-term disability is a continuous process as every disability insurance company will evaluate your eligibility for benefits on a monthly basis. You can never let your guard down and assume that your disability company will continue to pay your benefits for as long as you think you need them.

Our law firm offers a reasonable flat fee monthly claim handling service in which we handle every aspect of your long-term disability claim and do whatever it takes to make sure you are paid every month.

Negotiate a Lump-Sum Settlement

Let's discuss if a lump-sum settlement or buyout of your disability insurance claim is both available and makes financial sense for you. Our lawyers have negotiated more than five-hundred million dollars in disability insurance buyouts and we know how to get you a maximum settlement. A disability insurance company is not required to offer a buyout and not every disability company offers them.

Questions About Hiring Us

Who are Dell Disability Lawyers?

We are disability insurance lawyers that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.

In more than 98% of our cases, our lawyers have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement. Our lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.

We welcome you to contact any of our attorneys for a free immediate review of your disability claim. We also invite you to visit and subscribe to our YouTube channel where we have more than 700 videos and regularly provide tips to help protect your disability benefits.

Who do you help?

Our lawyers help individuals that have either purchased a long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer. We have helped individuals in almost every type of occupation with monthly disability benefit payments ranging from $1,500 to $50,000.

Our clients include all types of employees ranging from retail associates, sales representatives, government employees, police officers, teachers, janitors, nurses, pilots, truck drivers, financial advisors, doctors, dentists, veterinarians, lawyers, consultants, IT professionals, engineers, professional athletes, business owners, and high level executives.

A strong understanding and presentation of the duties of your occupation is essential for securing disability insurance benefits.

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via phone, email, fax, GoToMeeting sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-698-9159 or by email. Lawyers and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.