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 (and financially rewarding), our client was unfortunately forced to stop working in August 2017 due to significant heart issues. Fortunately, his employer provided him coverage under a Long Term Disability Insurance Policy with Sun Life Assurance Company of Canada should he ever be “unable to perform the Material and Substantial Duties of his Own Occupation.”
After stopping work on the advice of his treating physicians, our client applied for benefits under the LTD policy with Sun Life. Although benefits should have begun in November of 2017, by way of a denial letter of January 2018, Sun Life denied his claim. In support of its decision to deny these benefits, Sun Life stated that the “available records do not support a frequency of episodes requiring medical attention…” Sun Life pointed to the opinion of a physician consultant it had hired to perform a review of our client’s medical records. This reviewing consultant merely performed a paper review of medical records and never examined or met with our client. The reviewing consultant gave an opinion that our client only had restrictions of “no driving professionally, climbing, or lift/carry more than 25 pound ever.” Using the results of this review, Sun Life stated that “the available information supports the ability to sustain full time capacity” and that he would be able to perform his sedentary occupation.
Appeal by Attorney Palamara
After receiving the denial letter, the former employee of Avanade found our firm and spoke with Attorney Alexander Palamara. Attorney Palamara quickly reviewed the denial letter and knew there was a disconnect in the information provided to Sun Life and how Sun Life interpreted those records. After ordering the claim file and all medical records from the treating providers, it was quickly seen that Sun Life and its reviewing consultant overlooked much.
First and foremost, Sun Life failed to fully analyze all of our client’s relevant diagnoses and failed to apply the restrictions and limitations of these diagnoses to our client’s actual job requirements. In fact, Sun Life even overlooked the fact that a significant requirement of our client’s job duties included frequent travel.
A timely appeal was filed pointing out the inadequacy of Sun Life’s reviews and conclusions. In addition to pointing to the supportive medical documentation, the appeal also pointed to the history of support from multiple treating providers who each stated that our client would be unable to work and that his restrictions and limitations would be permanent. The appeal also pointed to an overabundance of objective physical findings that showed cardiac disease including multiple positive EKGs, Carotid Dopplers, and Echocardiograms.
Claim Finally Approval
On October 21, 2018, we received word from Sun Life that it was approving his Long Term Disability Claim. Sun Life made the conclusion that “he meets the requirements to be considered Totally Disabled…”. Shortly thereafter, our client received a sizable benefit check for nearly a year of benefits and remains on claim at the present time. Although our client is relieved to be finally on claim, he knows that the fight will continue as his policy’s definition of disability changes after 24 months of benefits. At that point, we will have to prove to Sun Life that he is “unable to perform with reasonably continuity any Gainful Occupation.” Thus, Attorney Palamara will continue to work on this claim to continue to prove to Sun Life that our client remains disabled and satisfies the requirements of the policy.
If you have been denied disability benefits by Sun Life or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.