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 elimination period in order to qualify for disability benefits. The plan administrator, Sun Life Assurance Co., was aware that the claimant had been awarded disability benefits by the Social Security Administration (SSA), but failed to review the SSA file or the determination of the Administrative Law Judge (ALJ) to award benefits. This was an error in that, according to the court, the only way claimant could have been awarded disability benefits under SSA’s rules is if the ALJ found “she could perform no job in the national economy, considering her age, education and work experience.” Additionally, SSA must have found the impairment had lasted or “will last for a year or more.”

Relevant Facts

After nearly five years of employment as a pharmaceutical sales representative with Daiichi Sankyo, Inc., plaintiff quit working and applied for disability benefits when neck pain and headaches, as well as depression and anxiety, interfered with her ability to do her job. In order to qualify for benefits, she had to prove she was unable to work in her own occupation during the entire 180-day elimination period as required by her disability plan. During this time, she was treated by several specialists including a neurologist and psychologist.

After reviewing reports from Green’s doctors, Sun Life decided that, although she had been disabled during part of the 180 days, she was not continuously disabled during the entire time. Based on this determination, Sun Life refused to award her disability benefits.

As part of the evidence presented in pursuit of her claim, Green’s attorney sent Sun Life a letter informing it that Green had been awarded disability benefits by the SSA, but the SSA file was not included with the letter and neither were the findings of the Administrative Law Judge (ALJ). Sun Life failed to request the SSA file and ALJ’s findings. It simply denied the claim for benefits on the grounds that she had not been continuously disabled for the entire time of the 180-day elimination period.

Analysis of the Decision by the Federal Court for the Northern District of Illinois

The federal court acknowledged that plan administrators are not required to award disability benefits to claimant’s just because the SSA awards benefits. But, it held that, “Sun Life’s failure to explain its reasons for disagreeing with the ALJ’s determination renders its denial arbitrary and capricious, particularly given the structural conflict of interest at play here.”

The court determined that, since the record was not developed, remand was the correct procedure with instructions that, after developing the record, “If Sun Life disagrees with the SSA ALJ’s rationale and the underling bases, Sun Life must explain why it reaches a different conclusion.”

This case was not handled by our office, but it may provide claimants guidance who have been granted disability benefits by the SSA, but are having problems convincing their insurer they deserve long term disability benefits under their employer benefit plan. If you need assistance with a similar matter, or any matter related to your claim for disability benefits, please contact any of our lawyers for a free consultation.

Leave a comment or ask us a question

Questions About Hiring Us

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 telephone, e-mail, fax, 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 800-682-8331 or by email. Lawyer 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.

Dell & Schaefer Client Reviews   *****

Leroy A.

I was referred to Dell & Schaefer after several years of dealing with my private disability insurance company and their refusal to pay me. Many law firms refused to take my case as it was not a Social Security Disability case. I retained another law firm prior to Dell & Schaefer and they were not able to get me paid. I was lucky to find Dell & Schaefer. They were able to settle with the disability insurance company to my satisfaction and recover disability benefits for me.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us