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Disability Attorney Argues Successfully for Reevaluation of Long-Term Disability Denial by SunLife

by

G. Dell

Logan Aluminum employee Vicky Costello left work on May 19, 2006 after a stressful confrontation with one of her coworkers. When her employer required her to sign a “last chance agreement” before she could return to work, she decided that she’d been suffering from debilitating pain long enough. It was time to file a disability claim through the long-term disability plan Logan Aluminum provided through Sun Life Assurance Company (Sun Life). She had been under a physician’s care since 1999. Little did she know how important a disability insurance attorney would be in her future.

Disability benefits application to Sun Life process begins. She filed her claim with Sun Life for long-term disability benefits on November 17, 2006. She also applied around the same time, as required by Sun Life for Social Security disability benefits. Her application with Social Security was approved. She supported her application to Sun Life with a written statement from the doctor that had been treating her since 1999, Dr. Simms. He indicated that she had been under treatment for rheumatoid arthritis, fibromyalgia and chronic fatigue. In his written statement, Dr. Simms reported that grasping and manipulating objects with her hands should no longer be expected of Costello, and she should no longer be expected to engage in activities that required bending, squatting, climbing, twisting, pushing, pulling, balancing, kneeling, crawling or lifting weights of more than 10 pounds. Sun Life denies disability claim. Costello’s claim was denied by Sun Life on January 16, 2007. The nurse that had reviewed her claim felt that Dr. Simms had not supported his claim that Costello was no longer able to work with sufficient evidence. Costello appealed the denial, providing notes from her December 14, 2006 appointment with Dr. Simms. In addition, she supplied a February 9, 2007 letter from Simms physician’s assistant who had the qualifications to state that Costello did have severe rheumatoid arthritis and that she was no longer able to return to any type of employment. She also presented an April 19, 2007 letter from Dr. Cudapagh, the physician who was treating her for fibromyalgia and chronic fatigue. This letter stated that the demands of working full time exceeded her functional and cognitive abilities. Sun Life responded by hiring a board certified rheumatologist, Dr. Ash, to review Costello’s documentation. He concluded, after reviewing the notes from her physicians, that her rheumatoid arthritis was not severe enough to prevent her from working and that her fibromyalgia would not be aggravated by her routine work duties. As far as he was concerned chronic fatigue was medical fiction. Based on these finding Sun Life denied Costello’s appeal on June 1, 2007.Disability Attorney

Argues That Sun Lifes Denial Is Arbitrary.

Having exhausted her administrative remedies, Costello had only one option remaining. Seek the assistance of a disability insurance attorney and file a lawsuit. She did so. Her disability attorney used three primary arguments to defend her rights to long-term disability benefits. The first argument centered on the fact that Sun Life had discretionary authority to both interpret and apply the plan. They were required to offer a reasonable explanation as to why they were denying her claim. Sun Life had failed to do this. The second argument centered on the fact that Costello had been recognized by Social Security disability insurance as being disabled, but Sun Life had failed to recognize this. The third argument presented by Costellos disability insurance attorney centered on the fact that the two professionals that Sun Life depended on for making the claims decision had never seen Costello. Rather than considering the information submitted by her physicians, Sun Life had preferred to accept the evaluation of that information by the two individuals they hired. Court Agrees with Argument of Disability Attorney that Sun Life Conflict of Interest Exists. The Court chose to review Costello’s case under the arbitrary and capricious standard of review because they found that Sun Life was both the administrator of the disability insurance plan, and it was the decision-maker as to whether Costello qualified for disability insurance. Court Disagrees with Sun Life on the Importance of Social Security Disability Approval Sun Life argued that the rules for acceptance under their long-term disability plan and Social Security were different. But the Court felt that because Sun Life had required Costello to apply for Social Security disability at the same time that she submitted her claim to Sun Life, Sun Life should have at least considered the Social Security disability approval as evidence that Costello was disabled. Court Finds Explanation of Denial Unreasonable The Court looked at Sun Life’s failure to require an independent medical examination unfavorably. Dr. Ash had discredited the statements relating to her pain without examining her, thus his conclusions had no basis in fact. They were only opinions. The Court recognized that paper reviews are often perfectly acceptable, but the bias demonstrated by this physician against fibromyalgia did not speak well of his evaluation of the medical record. To base the denial decision upon these faulty evaluations of the medical record was not principled, nor was the reasoning process deliberate. At the same time, the Court felt that the medical record did not supply adequate evidence to reach a conclusion that Costello was disabled. The Court was unwilling to award Costello summary judgment. Instead the Court sent the case back to Sun Life for a full and fair review. Costello will still need her disability attorney to guide her through the process of making sure that the information she supplies to Sun Life supports the claim that she is disabled. They have won one battle, but the war is not over.

About the author: Gregory Michael Dell is a

disability attorney

and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of disability attorneys have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. You can visit diAttorney.com for a free consultation, FAQ, videos and resolved cases archive.

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