Dell & Schaefer convinces Sun Life to Overturn Denial of Long Term Disability Benefits for a Person Suffering from Severe Cervical Disorders
Author: Attorney Alex Palamara
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 serious medical disorders. She was suffering from Regional Pain Syndrome, Chronic Neck Pain status post C6/7 Interbody Fusion of Fracture, Cervicalgia, Left C6/7 Facet Fracture, Degenerative Disc Disease of the Cervical Spine, C5/6 Foraminal Stenosis, Bilateral Shoulder Pain, Calcific Tendinitis, Left Shoulder Rotator Cuff Impingement, Low Back Pain, Enthesopathy of the Hips, Right Hip and Thigh Paresthesias and Dysesthesis, Bilateral Hip Pain, Left Hip Muscle Tears, Right Hip Recurrent Bursitis and Tendinitis, Left Gluteal Pain, Headaches/Migraines, Sjogren’s Disease, Fibromyalgia, Sicca Syndrome, Meralgia Paresthetica, Myalgias/Myositis, Dysphagia, Reflux Disease, Autonomic Dysreflexia, Abdominal Pain, Left Hand Dupuytren’s Contracture, Xerostomia, Xerophthalmia and Adjustment Disorder with Depressed Mood. Luckily for her, her employment at FLSmidth, Inc. provided her with a Long Term Disability Insurance Policy that would pay her a percentage of her monthly earnings should she be “unable to perform the Material and Substantial Duties of (her) Own Occupation.”
After being forced to stop working as a “Senior Procurement Agent” in early February of 2012, this FLSmidth employee filed a claim for LTD benefits shortly afterward. By way of a letter dated September 25, 2012, Sun Life informed the FLSmidth employee that it was approving her claim for LTD benefits as it found that she satisfied the terms of the policy. In May of 2013, the FLSmidth employee was approved for Social Security Disability Benefits by the Social Security Administration as it also found her to be disabled. LTD Benefits were paid by Sun Life through August 31, 2014. Unfortunately for the FLSmidth employee, by way of a denial letter dated September 2, 2014, she was informed that her benefits would cease.
In the September 2, 2014 letter, Sun Life concluded “that the medical documentation in (her) file does not support that (she) remain precluded from performing sustained light or sedentary level activities.” Sun Life continued that because it believes her prior occupation to be sedentary work as it is perform in the national economy, Sun Life determined that the FLSmidth employee’s “inability to perform the Material and Substantial Duties of (her) Own Occupation is not supported.” As such, Sun Life found that she did not continue to meet the definition of Total Disability as defined by the policy and as such denied her continued claim for benefits. In support of its conclusions, Sun Life relied upon two “paper” reviews by “medical consultants.”
Finding Dell & Schaefer
Within days of receiving the denial letter from Sun Life, the FLSmidth employee found attorney Alexander Palamara at the law firm of Dell & Schaefer. After a quick review of the case, the attorney realized that Sun Life’s decision was blatantly incorrect and agreed to assist the former Senior Procurement Agent with her administrative appeal. Dell & Schaefer immediately ordered a copy of the claim file from Sun Life so that it could review the materials Sun Life relied upon to deny the claim. Updated medical records and the disability claim file from the Social Security Administration were also ordered and reviewed. A review of all the documents confirmed our initial suspicion that Sun Life’s decision was incorrect and that it should immediately reinstate the FLSmidth employee’s claim.
Administrative Appeal Filed
Within a few months of contacting Dell & Schaefer, a timely administrative appeal was filed that challenged Sun Life’s decision to deny continued LTD benefits. The appeal focused on the objective evidence that exists which supports the FLSmidth employee’s inability to perform the material and substantial duties of her own occupation. The appeal also demonstrated the support that the FLSmidth employee continued to receive from her treating physicians who stated she was unable to work. Lastly, the appeal shredded the “independent” paper reviews conducted by Sun Life and Sun Life’s usage of them. Overall, the appeal was able to show the strengths of the claim and the incompetence of Sun Life’s review and decision.
Within 90 days of the appeal being filed, Sun Life informed us by way of a letter dated May 27, 2015 that its “appeals department had concluded that the documentation on file does support that your client is considered Totally Disabled from performing her Own Occupation as defined by the Group Policy.” Although our client is relieved to be back on claim, she knows that the fight to remain on claim will continue with Sun Life. Furthermore, she is aware that the definition of disability (what it means to be disabled under the policy) changes after 60 months of benefits. At that point, we will have to prove to Sun Life that she is “unable to perform with reasonably continuity any Gainful Occupation for which (she) is or becomes reasonably qualified by education, training or experience.”
Our client knows that Dell & Schaefer will continue to do whatever it takes to keep her on claim until her policy expires or until she is ready and able to return to work.
If you have been denied disability benefits by Sun Life or any other disability insurance provider, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer for a free consultation.