Our client, Ms. L, formerly worked as a Technology Teacher for a public high school in Massachusetts. For many years Ms. L suffered from chronic debilitating effects of multiple physical conditions and ailments, including most notably severe degenerative joint disease and osteoarthritis, which left her with debilitating physical pain and occupational impairments. Ms. L was unwilling to give up his career and worked as long as she possibly could. As a result of her serious medical conditions and associated restrictions and limitations, Ms. L was forced to stop working in January 2019 and apply for disability benefits under her employer’s Long Term Disability (LTD) Policy, which was administered and funded by Sun Life. However, Sun Life denied LTD benefits after it determined that the medical evidence does not support Ms. L’s claim that she was precluded from performing the material and substantial duties of her own occupation.
After receiving the denial, Ms. L contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds, who identified several significant issues in Sun Life’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. L’s ERISA appeal with the assistance of his appeal team.
The appeal addressed all of Sun Life’s short-comings and reasons for denial. In particular, the appeal argued that Sun Life’s occupational analysis confirmed that Ms. L’s position as a high school teacher required standing and walking to a significant degree (6 hours in an 8 hour day) and was considered to be “light duty”. And review of the claim file confirmed that Sun Life had in their possession clear objective testing – an MRI – of Ms. L’s afflicted joint(s) that was positive for nondisplaced degenerative tear surrounding the soft tissue and an underling bone marrow edema; advanced tri-compartmental cartilage loss as well as a subsequent X-ray that was positive for advanced degenerative changes with joint space narrowing in the medial compartment. Clearly, the objective testing did not support the ability to perform light duty work requiring extensive standing/walking.
The appeal next argued the significant disparity in Sun Life’s medical reviews versus Ms. L’s treatment providers. Specifically, from a medical standpoint Sun Life’s denial relied exclusively on a “specialist review” completed by Sun Life’s own in-house nurse whose credentials and experience were unknown. Conversely, Ms. L’s claim was supported by all of her treatment providers, which included three (3) different board certified orthopedic surgeons, all of whom were clinical instructors at Harvard Medical School and maintained full-time clinical practices at Massachusetts General Hospital. What’s more, unlike each of these three experts, Sun Life’s nurse did not actually examine Ms. L or even speak with her.
Finally, the appeal noted that the record evidence clearly establishes that Sun Life operated under a significant financial conflict of interest in its purported investigation of and determination on Ms. L’s LTD claim. Sun Life’s attempt to avoid significant financial liability by claiming Ms. L could return to her light occupation by relying on unsupported and unreasonable medical record reviews by an in-house nurse consultant made clear that Sun Life operated under a significant and ongoing financial conflict of interest in deciding Ms. L’s claim.
Just over nine weeks after filing her appeal, and after reviewing hundreds of pages of exhibits and medical records, Sun Life overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. L’s LTD benefits. 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.