Prior to filing for disability our client worked as a Surgical Services Director for a large hospital system. Her occupation came with an incredible amount of responsibilities relating to the efficient and safe operation of the surgical department of a hospital- requiring her to not only have to be mentally alert, but also physically available on a moment’s notice throughout the hospital. This was a tall order for anyone, let alone someone with a long history of cervical and lumbar spine conditions with associated radiculopathy, arthritis, migraines and neuralgias. Eventually the pace of her job and the continued deterioration of her health left her unable to adequately perform her duties, which in turn left her with little choice but to file for disability benefits under her employer’s policy with Sun Life.
The Initial Denial of Benefits
Despite overwhelming support from her doctors and from her supervisors at work, Sun Life determined that our client was not eligible for benefits under the policy. The basis of the denial is due in large part how Sun Life often interprets its own policy, with specific attention to the definition of disability and “own occupation.” Our client’s policy had very standard language as it relates to disability- the inability to perform the Material and Substantial Duties of your Own Occupation. However, instead of reviewing one’s ability to perform the actual duties required of her job, Sun Life only took into consideration the physical demand level associated with our client’s occupation as set forth by the Department of Labor- or more commonly argued, the “national economy standard.” In this case, Sun Life stated that there was a lack of medical information to support our client’s inability to perform “Sedentary” work without any real consideration to her actual occupational duties.
The Administrative Appeal
Following the denial of her claim our client reached out to Attorney Stephen Jessup as he had previously represented and successfully secured disability benefits for a friend of hers. In reviewing Sun Life’s claim file Attorney Jessup’s attention was initially drawn to the concerns relating to Sun Life’s occupational review, which he felt created an unfair standard of disability that was not contained in the policy. However, knowing that Sun Life’s review of our client’s appeal would be heavily dependent on evidence with respect to her physical ability to work Attorney Jessup had her undergo a Functional Capacity Evaluation. The purpose of the FCE was to draw a correlation between our client’s diagnosis and her functional restrictions and limitations as they relate to work based on same. The results of the FCE did indicate our client retained some ability to work at a Sedentary demand level, but not on a full time basis or with reasonable continuity. In light of these findings Attorney Jessup gathered additional statements and letters of support from our client’s attending physicians to further undermine Sun Life’s doctor’s opinions. Armed with an abundance of additional objective medical evidence of disability Attorney Jessup submitted an appeal that was over 1000 pages of argument and medical information on our client’s behalf.
Following an appeal review that included Sun Life exercising its right to an extension of time to make a decision, Sun Life, faced with overwhelming evidence of disability and argument as to entitlement of same, overturned its denial of our client’s benefits. However, like many insureds, our client is not out of the woods yet as her policy contains a change in definition to the inability to perform the duties of “any occupation” after 24 months of long term disability benefits. Attorney Jessup continues to represent our client to best ensure that Sun Life will not be able to terminate her benefit at that time.