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Ben Glass
Ben Glass
Attorney • (703) 584-7277

LONG TERM INSURANCE COMPANY ORDERED TO PAY BENEFITS.

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In a recent case decided by the Fourth Circuit Court of Appeals Sun Life Assurance Company was ordered to pay benefits to a woman who suffered severe and chronic pain in her lower back, buttocks and legs.

The court said that a long-term disability insurance company’s decision to deny benefits must be rationally supportable which in turn requires that it be the “result of a deliberate, principled reasoning process” and “supported by substantial evidence.” The court said that in order to deny benefits the insurance company must present a basis “a reasoning mind would accept as sufficient” to support its decision.

Here the court rejected Sun Life’s decision to deny benefits because it felt that “the opinions of the treating physicians conflicted.” The court found that the treating physicians did not submit conflicting reports but instead collaborated by referring the patient to different doctors for different aspects of her care.

The insurance company had the plaintiff’s records reviewed by a so-called independent physician consultant who never examined the patient or spoke to any of the patient’s doctors. The court found that while his two one page letters expressed skepticism about the claimant’s disability, his conclusions lacked support in the medical records. The court also found that at least one of his conclusions was flatly incorrect. The court also rejected the opinion of a vocational consultant who did not examine the claimant.

Finally, Sun Life suggested that the claimant suffered from depression that was due to psychiatric problems but the claimant “refused to treat.” Again the court rejected this suggestion since all of the treating physicians were of the opinion that the claimant suffered from depression from her chronic pain and that it was not depression which was the cause of her disability.

Comment from Virginia long-term disability attorney Ben Glass: This is a refreshingly well thought out decision by the Fourth Circuit Court of Appeals. ERISA long-term disability claims are extraordinarily difficult and the law is heavily tilted in favor of the insurance companies. Here Sun Life Assurance Company of Canada tried to get out of paying a claim based on a clear technicality and not based on the well-established law of ERISA.