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.”
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.