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, fibromyalgia, chronic fatigue, neuropathy, bilateral hip pain, bilateral hip bursitis and bilateral knee osteoarthritis forced Ms. A to stop working and submit her claim for disability benefits, first under her employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by Sun Life. Under her employer’s disability policy, after 24 months she would be considered totally disabled if she was unable to perform the main duties of “any occupation” for which she was qualified by education, training and experience and with additional consideration of her functional limitations and transferable skills.
After paying Ms. A for 24 months under the Policy’s “own occupation” definition of disability, Sun Life denied continued LTD benefits on the basis that she allegedly no longer met the policy definition of disability. Specifically, Sun Life stated that “the medical evidence does not support that [Ms. A] would be precluded from performing the Material and Substantial Duties of any Gainful Occupation.” After receiving the denial, Ms. A contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Sun Life’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. A’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Sun Life’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Sun Life’s denial and significant inconsistencies with its medical reviewer’s findings. In particular, the appeal addressed several inconsistencies and misinterpretations of medical information submitted by Ms. A’s primary treatment provider and the extent to which Ms. A was functionally limited. The appeal also questioned the findings of an Employability Assessment/Transferable Skills Analysis conducted by Sun Life based on misinterpretation of the APS submitted as well as the failure to evaluate whether Ms. A could perform a sedentary occupation with “reasonable continuity,” which the medical record confirmed she could not.
Just over two months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Sun Life overturned its decision to terminate benefits and negotiated a reasonable settlement of Ms. A’s long-term disability benefits claim.