Court Remands Sun Life to Consider Social Security's Decision to Award Plaintiff Disability Benefits
In Green v. Sun Life Assurance Co., the issue concerned whether or not the claimant was continuously disabled during the 180-day required elimination period in order to qualify for disability benefits. The plan administrator, Sun Life Assurance Co., was aware that the claimant had been awarded disability benefits by the Social Security Administration (SSA), but failed to review the SSA file or the determination of the Administrative Law Judge (ALJ) to award benefits. This was an error in that, according to the court, the only way claimant could have been awarded disability benefits under SSA’s rules is if the ALJ found “she could perform no job in the national economy, considering her age, education and work experience.” Additionally, SSA must have found the impairment had lasted or “will last for a year or more.”
Relevant Facts
After nearly five years of employment as a pharmaceutical sales representative with Daiichi Sankyo, Inc., plaintiff quit working and applied for disability benefits when neck pain and headaches, as well as depression and anxiety, interfered with her ability to do her job. In order to qualify for benefits, she had to prove she was unable to work in her own occupation during the entire 180-day elimination period as required by her disability plan. During this time, she was treated by several specialists including a neurologist and psychologist.
After reviewing reports from Green’s doctors, Sun Life decided that, although she had been disabled during part of the 180 days, she was not continuously disabled during the entire time. Based on this determination, Sun Life refused to award her disability benefits.
As part of the evidence presented in pursuit of her claim, Green’s attorney sent Sun Life a letter informing it that Green had been awarded disability benefits by the SSA, but the SSA file was not included with the letter and neither were the findings of the Administrative Law Judge (ALJ). Sun Life failed to request the SSA file and ALJ’s findings. It simply denied the claim for benefits on the grounds that she had not been continuously disabled for the entire time of the 180-day elimination period.
Analysis of the Decision by the Federal Court for the Northern District of Illinois
The federal court acknowledged that plan administrators are not required to award disability benefits to claimant’s just because the SSA awards benefits. But, it held that, “Sun Life’s failure to explain its reasons for disagreeing with the ALJ’s determination renders its denial arbitrary and capricious, particularly given the structural conflict of interest at play here.”
The court determined that, since the record was not developed, remand was the correct procedure with instructions that, after developing the record, “If Sun Life disagrees with the SSA ALJ’s rationale and the underling bases, Sun Life must explain why it reaches a different conclusion.”
This case was not handled by our office, but it may provide claimants guidance who have been granted disability benefits by the SSA, but are having problems convincing their insurer they deserve long term disability benefits under their employer benefit plan. If you need assistance with a similar matter, or any matter related to your claim for disability benefits, please contact any of our lawyers for a free consultation.
Resources to Help You Win Disability Benefits
Submit a Strong Sun Life Appeal Package
We work with you, your doctors, and other experts to submit a very strong Sun Life appeal.
Sue Sun Life
We have filed thousands of disability denial lawsuits in federal Courts nationwide against Sun Life.
Get Your Sun Life Disability Application Approved
Prevent a Sun Life Disability Benefit Denial
Negotiate a Sun Life Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Policy Holder Rating
Unscrupulous Tactics
What a mess
Reply
They leave you unable to fight
Reply
Sun Life is a real pain
Reply
Everytime SunLife receives my information they ask for another 7 to 10 business days
Reply
I have lost everything due to non payment of my claim.
SunLife said if I don't apply for SSI they will lower my payments
Reply
I don't understand SunLife's overpayment letter
Reply
Q: Can SunLife offset dependent social security benefits received on account of my wife's disability?
Q: Does SunLife have a required time to make a decision? Can they request medical records that have nothing to do with my illness?
Q: What happens if a policy doesn't mention something I believe I had and paid for (COLA)?
Q: Can SunLife deny me on the basis on a preexisting condition?
Q: Can I sue SunLife if I signed a Settlement & Release Agreement?
Q: Can I still get my short term disability benefits if I'm terminated?
Q: Can I sue SunLife for pain and suffering?
Q: Should I be worried that SunLife is trying to deny my claim by making it seem like I have a mental disorder? Can they deny my claim if I refuse to undergo this needless psychiatric assessment?
Tips for Applying for Sun Life Disability Insurance Benefits
Can a Disability Claimant Refuse to Attend an IME During an Appeal?
Why Must Your Disability Insurance Lawyer Understand Your Disabling Condition?
Disability Benefit Denial Reason #5 – Your Medical Evidence is Weak
Disability Benefit Denial Reason #4 - Your Doctor Is Misled By the Disability Company
Disability Benefit Denial Reason #3 - Video & Social Media Surveillance
How Do You Fight a Long-Term Disability Denial?
Disability Denial Reason #2 - Change of Disability Definition & Vocational Review
Sun Life Wrongfully Denies Disability After Paying For 23 Months
Sun Life Overturns Its Previous Denial of LTD Benefits for Massachusetts Teacher
After Appeal Sun Life Finally Approves Disability Benefits for Data Engineer
Sun Life overturned previous denial of LTD for California Diagnostics Manager
Unum and Sun Life approve disability benefits to OB/GYN
After appeal filed by Attorney Jay Symonds, Sun Life overturned its previous denial of long term disability benefits for Florida ICU Nurse
Sun Life Approves Disability Benefits to Surgical Services Director
Sun Life ignored its own medical expert's opinions supporting registered nurse's inability to work in a sedentary occupation due to severe rheumatoid arthritis
Reviews from Our Clients






