Sherry DeLisle worked as a Director of Operations for a retail jeweler from 1996 until 2002. In 1998, she suffered head, neck and back injuries during a car crash. As a result she underwent a full anterior spinal fusion. Then, in 2000, she was involved in another car accident which re-injured her spine and caused a closed head injury.
As a result of the accidents, she suffered from a number of impairments, including:
- Degenerative disc disease
- Closed head injury
- Chronic pain syndrome
- Post traumatic syndrome
- Major depressive disorder
- Class 5 mental impairment
In 2002, she was fired from her job because, according to the employer, she was not doing her job. The employer did not specify what that meant. About seven months later, she pursued disability insurance benefits through her employer’s long term disability insurance policy with Sun Life.
Ms. Delisle Submitted Sufficient Evidence of Disability
As part of her claim for long term disability benefits, Ms. DeLisle submitted medical records and five attending physician statements all concluding she wa disabled from performing her own job as of the last day she worked for the jeweler. Sun Life reviewed her claim using three medical consultants. It was ultimately denied because Sun Life determined she was not disabled as of her last day worked. Ms. DeLisle properly submitted an appeal to Sun Life.
In 2003, she was found disabled by the Social Security Administration (“SSA”) and awarded Social Security Disability Income (“SSDI”) benefits. SSA determined she was disabled as of April 17, 2002, the last she worked for the jeweler.
During the appeal, Sun Life reviewed her claim using three more medical consultants. The claim file reveals that Sun Life did not give much credit to her SSDI award and it presented some of Ms. DeLisle’s evidence to its medical consults in a negative light.
Sun Life denied the appeal, again finding she was not disabled as of her last day worked. Ms. DeLisle timely filed a lawsuit under the Employee Retirement Income Security Act (“ERISA”) and the lower court ruled in her favor. Sun Life appealed the decision to the appellate court.
Michigan Appellate Court found Sun Life Unreasonably Denied LTD Benefits
ERISA disability insurance cases require a court review the case under a higher than normal standard of review. This means the Court reviews the case giving defence to the insurance company. The court must find the insurer acted arbitrary and capricious, or unreasonable, to rule in favor of the claimant.
Here, the Court found Sun Life acted unreasonably for main three reasons:
It acted with a conflict of interest because it was the claim evaluator and payor.
This means the Court took into consideration that Sun Life evaluates the claim and also pays benefits out of its own assets. There is an incentive for Sun Life to deny claims to avoid paying benefits.
This is also important because the Court looked at the six medical consultants Sun Life used to review the medical evidence. Five of the six consultants were regularly contracted with Sun Life to review disability claims. This shows that they, too, had a financial incentive to not support disability because they will continue to get work from Sun Life.
It improperly ignored the SSDI award.
An SSDI award does not automatically mean you will be awarded LTD under the LTD policy. However, Courts look at how the insurance company reviewed the SSDI award and the circumstances around it.
- Did the insurance company encourage or require the claimant to file for SSDI?
- Does the insurance company get to deduct the SSDI award from the benefits they will pay?
- Did the insurance company fail to properly explain why it was making a different detmeraiton than SSA?
If the answer to these questions is yes, then the court must take it into consideration when determining whether the insurance company acted reasonably or in its own self interest.
The weight of the medical evidence supported disability.
Ms. DeLisle’s medical records leading up to her date of disability reflect the symptoms and conditions from which she was suffering. Her doctors noted that she had a progressive condition and advised her to stop working months before she actually did. The medical records dated after she stopped working also demonstrated her symptoms and conditions.
Sun Life’s medical reviewers mostly agreed with the diagnoses but did not agree with the effect they had on her functionality, specifically on whether she could work. The Court found that the medical evidence was not properly reviewed and considered which led to an unreasonable denial of benefits.
This case demonstrates the importance of analyzing not just your own medical evidence but the evidence created by the insurance company.
Help from a Lawyer with Expertise in Disability Insurance
Disability insurance law is complex. Hiring an experienced disability attorney is important. Because all disability lawyers at this law firm focus on disability insurance claims, we have expertise in disability insurance law.
That means have:
- Experience with every major disability insurance company;
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And, we never charge fees or costs unless our clients get paid.
- Submitting a disability insurance claim;
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- Filing a lawsuit against your disability insurance company.
The firm represents clients nationwide with disability claims governed by federal law, even if we are not located in your state.