Bartolic Law helps clients with long-term disability claims denied by Sun Life. In one case, our client suffered from Chronic Fatigue Syndrome and Sun Life denied the long-term disability claim and terminated short-term disability benefits after initially approving short-term disability. Sun Life conducted a background investigation of our client, including interviewing neighbors and contacting the fitness center where the client was a member regarding the frequency of attendance. It also demanded the client attend an Independent Medical Examination. We attended with the client to document the process. With photographs of the clock when our client began and ended the examination, and the client’s written explanation of the client’s inability to stay awake while waiting for the doctor, we got our client’s claim denial turned into an approval. In another case, Sun Life denied long-term disability benefits following a sudden cardiac death because the client had a pre-existing condition of heart disease. With considerable digging into medical causation and close work with the client’s doctors, we persuaded Sun Life the sudden cardiac death was an event not influenced at all by the heart disease, allowing our client to live an early retirement with financial dignity.
ERISA regulations require an insurer to decide an appeal within 45 days unless “special circumstances” apply, preventing the insurer from being able to meet the deadline, allowing a single 45-day extension. For a discussion of what constitutes “special circumstances,” see our blog post.
When an insurer asserts its deadline is extended, make sure to ask why, and what steps it took to meet the 45-day deadline. The reasons given often do not meet the requirements of “special circumstances.”
Ferrin v. Aetna Life Ins. Co., 336 F. Supp. 3d 910 (N.D. Ill. Sept. 28, 2018) (holding insurance policy’s grant of discretionary authority is void under Texas law due to certificate being issued after effective date of regulation, and policy renewing after effective date, and holding Plaintiff was disabled from Any Reasonable Occupation where treating doctors certify she can sit at the occasional level, and insurer’s consultants opine Plaintiff can sit frequently, as weighing all evidence together would make capacity likely at low end of frequent range at best).
Sadowski v. Tuckpointers Local 52 Health & Welfare Trust, 281 F. Supp. 3d 710 (N.D. Ill. Dec. 20, 2017) (holding plan was arbitrary and capricious in denying medical benefits for removal of spinal cord stimulator following a fall down the stairs and infection where plan argued the expenses were caused by the same injury as the car accident necessitating implantation of the stimulator years earlier)
Tassone v. United of Omaha Life Ins. Co., 264 F. Supp. 3d 867 (N.D. Ill. Aug. 30, 2017) (awarding client long term disability benefits denied by United of Omaha despite insurer’s doctor opining there was no objective evidence of functional impairment)
Suson v. PNC Fin. Servs. Grp., Inc., No. 15-CV-10817, 2017 WL 3234809 (N.D. Ill. July 31, 2017) (holding Liberty Mutual’s denial of client’s long term disability benefits was arbitrary and capricious where Liberty Mutual disregarded client’s carpal tunnel syndrome and relied on a vocational opinion to which client never had an opportunity to address before litigation)