Sun Life Approves LTD and LWOP Claims after Medical Examination

A Saleswoman was rendered disabled as a result of intractable occipital neuralgia, cervical degenerative disc disease, cervical spondylosis, spasmodic torticollis, postlaminectomy syndrome, chronic pain syndrome, and chronic migraines.

After paying long-term disability (LTD) benefits for just over a year and approving life insurance waiver of premium (LWOP) for just under a year, Sun Life Assurance Company of Canada (Sun Life) terminated both claims.

The terminations were based on a physician review, occupational analysis and video surveillance.

Our saleswoman client requested an extension of time to submit a comprehensive internal appeal to Sun Life. In response, Sun Life identified certain conditions upon which the tolling would be allowed, including an agreement that the Saleswoman undergo a so-called “independent medical examination” (IME) (we refer to these as “insurance” not “independent” medical exams) by a psychologist. Notably, the request for conditions was authored by Sun Life’s outside counsel, who interjected himself into the appeal process in violation of the principals governing ERISA claims. After negotiating the terms of the extension to accommodate the claims handler’s vacation schedule and the IME, McDermott Law, LLC submitted an appeal of the adverse benefit determinations. The Saleswoman then underwent the IME to evaluate her non-disabling psychological conditions.

Less than a month after receiving the appeal, Sun Life overturned its prior adverse benefit determinations. In approving the claims, Sun Life agreed that the Saleswoman was disabled as a result of her physical, not mental, conditions.

Even though a disability or life insurance policy may require that a claimant submit to an IME upon request of the insurance company, certain conditions can be imposed on that process to help ensure a more impartial examination. Without such conditions and the advice of legal counsel, a claimant is left without any recourse to overcome a biased IME and is unprepared with regard to the IME process.

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