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Sun Life overturned previous denial of LTD for California Diagnostics Manager

Attorney Jay SymondsAuthor: Attorney Jay Symonds

Our client, Ms. G, formerly worked as a Diagnostics Manager for a regional Healthcare System. In October 2016 a number of medical issues, including Stage IV Ovarian Cancer Neoplastic Fatigue, Major Depressive Disorder, Language Disorder and Cognitive Impairment forced Ms. G to stop working and submit her claim for disability benefits under her employer’s long-term disability (LTD) policy, which was funded and administered by Sun Life. Under her employer’s disability policy she would be considered totally disabled if she was unable to perform, with reasonable continuity, the material and substantial acts necessary to pursue her usual occupation in the usual or customary way.

After paying Ms. G for 9 months under the Policy’s “own occupation” definition of disability, Sun Life denied continued LTD benefits on the basis that she allegedly no longer met the policy definition of disability. Specifically, Sun Life “concluded that she is not medically unable to perform the duties of her Own Occupation.” After receiving the denial, Ms. G contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Sun Life’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. G’s ERISA appeal with the assistance of his appeal team.

The LTD appeal addressed all of Sun Life’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Sun Life’s denial and significant inconsistencies with its medical reviewer’s findings. In particular, the appeal addressed the fact that, despite significant medical evidence supporting that Ms. G suffered from significant chemotherapy induced cognitive deficits or chemo brain, Sun Life’s medical records reviewer was not asked to address Ms. G’s significant cognitive deficits but instead was specifically instructed to limit his review to “physical diagnosis only.” Further, although Sun Life’s reviewer claimed Ms. G was “free of disease” medical testing confirmed that her CA 125 levels were rising and she was actually suffering a recurrence of the disease. And her cognitive issues had reached such levels that her treatment providers were considering a referral to a Neurocognitive Institute for evaluation.

Finally, Sun Life attempted to reclassify Ms. G’s cognitive issues as if they were the same as those associated with other specific illnesses like Parkinson’s disease when they clearly are not. It is well documented that cancer survivors who experience these symptoms often score in normal ranges on memory tests. It is not clear what causes chemo brain, no cure has been identified, and no standard treatment has been developed for cancer-related memory problems because symptoms and severity differ from person to person. Instead doctors work to develop an individualized approach to coping.

In addition, Attorney Symonds filed an appeal on behalf of Ms. G with respect to Sun Life’s denial of her Life Insurance Waiver of Premium (LWOP) claim. Under the life policy Ms. G would be considered totally disabled if she was unable to perform “any occupation” she was qualified to perform.

Just over three months later, and after reviewing both appeals and hundreds of pages of exhibits and medical records, Sun Life overturned both decisions to terminate benefits, paid full LTD back benefits and reinstated Ms. G’s LTD benefits and WOP status. Attorney Symonds continues to represent our client to best ensure that Sun Life will not terminate her benefits again. Feel free to call our disability attorneys for a free consultation regarding any matter relevant to your disability claim.



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