Vehicle Salesperson Wins Sun Life LTD Insurance Appeal for Osteoarthritis

We represent a 57 year-old claimant who’s occupation was selling commercial vehicles for many years.  Her job was very physical as it required her to climb in and out of semi-trucks multiple times a day as well as operate them which was very strenuous. She went out of work in due to ongoing and severe debilitating right hip, low back, and bilateral knee pain stemming from multiple medical conditions including hip arthritis, lumbar degenerative disc disease, osteoarthritis, and comorbidities to include thyroid disease, hyperlipidemia, migraines, GERD, and osteoporosis. She underwent two total hip replacements which unfortunately did not relieve her pain. She was no longer able to perform with reasonable continuity the material and substantial duties of her occupation or any gainful occupation for which she is or could become reasonably qualified for by education, training, and experience. Sun Life approved her claim for 23 months and just before the change in definition from own occupation to any gainful occupation, they terminated her benefits based solely on a Nurse practitioner’s review of her medical records. In addition, Sun Life improperly re-classed her previous job as sedentary when they had previously classed her occupation as falling under light duty. Sun Life failed to send her for an IME or FCE and never had spoken to any of her treating physicians who were all clearly supportive of her inability to work. That’s when she retained our services to handle her appeal.

In our appeal we were able to show that there were no proper grounds upon which to terminate benefits  as the totality of the medical evidence to include the opinions of her treating physicians continued to support a severity of impairment that would preclude her ability to perform the material duties of her own occupation (whether sedentary or light) or any gainful occupation. Physical Medical Source Statements dated January 27, 2021 and March 12, 2021, from Dr. Gautham Reddy (PCP) and Dr. Steven Hoer (Orthopedic Surgeon) documented restrictions and limitations due to her severe medical conditions that substantiated her physical capacity fell below sedentary. Additionally, in a letter dated January 29, 2021, Dr. Art Louie confirmed Ms. her inability to work in any capacity as a result of her condition.

Our client remains under treatment for her debilitating right hip, low back, and bilateral knee pain. Her orthopedic follow up on February 2, 2021, reflected that her knees are unstable and bilateral knee braces along with physical therapy were recommended. Lumbar x-ray was noted to demonstrate severe degenerative spondylosis, disc space narrowing at L4-5, and moderate bilateral SI joint degenerative disc disease. X-rays of knees was noted to demonstrate mild medial and lateral osteoarthritis on left and mild medial tricompartmental osteoarthritis on right. Subsequent orthopedic follow up documented ongoing anterior thigh pain with cramping  as well as groin pain both of which increased with activity. Her severe pain symptomatology was noted to be refractory to treatment including pain medications.

A functional capacity evaluation (FCE) performed on October 20, 2021 confirmed that her residual functional capacity fell below sedentary; therefore, she is, in fact, unable to physically perform the material and substantial duties of her own occupation or any gainful occupation. The FCE which is deemed a valid and reliable representation of her physical capacity reflected that she was unable to sit or stand for more than one-third of an eight-hour work day. Her primary limitations are noted as:

• impaired sitting, standing, and walking tolerance
• squatting, kneeling, and climbing impairment
• intolerance for sustained activity in any position

After reviewing our compelling appeal, Sun Life overturned their decision to terminate her benefits and paid her the back benefits she was owed. She is currently on claim and receiving monthly benefit checks.