Sun Life Disability Claim Denial Reversed on Appeal for Funeral Home Director with Chronic Pain and Migraines

Prior to Sun Life’s denial of her claim for long term disability, our client had been on claim for just over a year due to her inability to perform the duties of her pre-disability “own occupation” as a Funeral Home Director due to a multitude of conditions that included: Cervical and Lumbar Stenosis with associated radiculopathy, degenerative joint disease, facet joint arthritis and migraine. As previously discussed on our website and in video, Sun Life has a reputation for offering a “low ball” lump sum settlement on a long term disability policy prior to denying a claim for benefits. Such was the case with our client who received a letter from Sun Life advising her that they were investigating her claim to determine if she was still disabled under the terms and conditions of the policy. In the letter Sun Life offered her a lump sum buyout that represented a small percentage of the actual value of her policy and followed the offer with language that indicated that Sun Life would be taking the “next steps in action plan if the proposal was not accepted.” Our client declined the unreasonable settlement amount.

“The Buyout Letter” and the “Next Steps In Action Plan If Proposal Was Not Accepted…”

What Sun Life should have said was if she didn’t accept the offer they were going to deny her long term disability benefit, which is exactly what occurred. In denying her claim for benefits they placed her under video surveillance and sent her file to be reviewed by a Registered Nurse and a Medical Doctor. Of particular interest is the fact that the Registered Nurse reviewer determined that our client would be unable to function at even a sedentary range of physical demands. In essence, the nurse indicated she would be unable to do any job, let alone her own occupation. This report was far from helpful to Sun Life, so they were forced to send her information to a medical doctor. To no surprise the reviewing doctor determined that she would be able to work at a medium physical demand level. With a hired gun on board and what amounted to inconsequential video surveillance, Sun Life terminated our client’s claim. One cannot help but wonder if the denial was also in retaliation to her refusal to settle her claim.

The ERISA Appeal Against Sun Life

Following the denial of her claim for benefits our client contacted Attorneys Dell and Schaefer and spoke with Attorney Stephen Jessup. Following review of the denial letter, Attorney Jessup explained to her that she was a casualty of a common strong arm tactic employed by Sun Life in denying claims. Attorney Jessup set to work quickly to obtain a complete copy of the claim file. Review of the claim file indicated that Sun Life failed to take into consideration the totality of our client’s medical conditions and the severity of same. As noted, Attorney Jessup discovered that Sun Life’s attempt to cut corners and save money by having our client’s claim reviewed by a Nurse as opposed to a Doctor had backfired on them. The subsequent review by the doctor was in turn met with amplified skepticism. Attorney Jessup set out to systematically attack the report of Sun Life’s reviewing doctor, which was riddled with inconsistency and an overall lack of information or understanding of our client’s pre-disability occupation. In order to combat the opinions expressed in the report, Attorney Jessup coordinated functional testing that would not only support our client’s inability to perform the duties of her former occupation, but also confirm the opinion of the initial Sun Life Nurse reviewer and further discredit the opinion of the reviewing medical doctor.

Following submission of the Appeal, Sun Life required our client attend an Independent Medical Examination. The request was met with suspicion by Attorney Jessup and our client as nothing more than Sun Life’s continued attempts to buy an opinion that would justify its denial. Attorney Jessup advised our client as to what to expect from the IME and what steps would be taken to ensure that it was truly as fair and independent as the name would imply. Ultimately, after months of not receiving benefits the truth prevailed and based upon the argument in the appeal and the additional information compiled in support of her disability contained therein, as well as the examination by the IME doctor, Sun Life was forced to admit its mistake and overturn its denial.

Does This Sound Familiar To You?

As indicated, Sun Life commonly sends a letter offering a lump sum buy out of a claim that if refused customarily results in a denial of your benefit. If Sun Life has sent you a similar letter, or you are concerned that Sun Life may deny your claim please contact Attorneys Dell and Schaefer for a free consultation.