When you go on the Sun Life long-term disability website, it greets you with a picture of a smiling person talking on a phone. It leads you to believe that they are pleased with the fact that they are getting home from a friendly insurance company. Alternatively, you can picture that person as the helpful Sun Life representative, paving your way to their income protection. Sun Life claims that its long-term disability services are “delivered with empathy and encouragement.”
An employee can be as empathetic as possible, but empathy means nothing if all they say is “sorry” when they reject your claim for benefits. You need the long-term disability benefits that Sun Life promised you as part of your insurance contract.
Insurance companies like Sun Life know that our disability claims attorneys at J. Price McNamara ERISA Insurance Claim Attorney mean business and will do what it takes to protect our client’s right to benefits. When we stand up to Sun Life and other large insurance providers, adjusters tend to listen and provide the benefits our clients need and deserve. Reach out today to learn more about our services and success stories.
In reality, Sun Life does say no, and they do it quite often. In one such case, Sun Life claimed that a woman with a rare disorder that led to impaired brain function was not totally disabled within the meaning of the plan. Sun Life would not even turn over the administrative file to the claimant to file an appeal.
In another case, a plaintiff had to fight Sun Life for 15 years to get long-term disability benefits after the company terminated his benefits. When the plaintiff finally won his long battle, Sun Life tried to go all the way to the United States Supreme Court (which would not take their case).
You get a sense of the measures that Sun Life will take and the lengths they will go to to protect their financial interests at your expense. Smiling faces on internet websites mean nothing when an insurance company will not pay you the benefits you deserve.
Based on our experience, here are some of the ways that Sun Life will try to make your life more difficult:
Sun Life is also notorious for denying claims and making low settlement offers when you appeal. Unfortunately, the way that ERISA works is that insurance companies have a wide berth to deny claims. They do not face the same bad faith claims that traditional long-term disability companies not subject to ERISA may face.
You need an attorney to fight for you because Sun Life is out to push you around and wear you down. They count on your being desperate and grateful to accept whatever small amount they offer you as a settlement. If the facts and the law are on your side, you do not need to sell your legal rights for pennies on the dollar.
In practice, the long-term disability benefits claims process is supposed to work like this:
On paper, this is how everything is supposed to work. Now, we will give you an idea of what happens in practice. Indeed, Sun Life does grant some claims immediate long-term disability benefits. Some injuries and illnesses are so severe that there is little doubt that the claimant cannot work.
However, for every clear-cut case, there is another where the insurance company does what many people know happens – they throw up barriers and roadblocks in the name of protecting their financial interests. You see, long-term disability claims can cost them millions of dollars over the life of the claim. You see yourself as someone who desperately needs this money because you can no longer earn a living. They see you as a drain on their bottom line that they need to keep off or kick off their payroll.
Many clients are shocked when Sun Life denies their benefits. They know their reality, and they have no idea how someone can deny what they are dealing with daily and expect them to work. The insurance company must provide a reason for denying your benefits, and new rules require much more transparency from them. The insurance company must provide you with the documents they relied on to deny your claim.
Common reasons for claim denial include:
If Sun Life denied your claim, you have the legal right to act. You do not just have to accept an arbitrary denial. If you did not hire a lawyer to help you prepare your claim (something you should consider), receiving the denial letter should prompt you to call one immediately. The insurance company will need to explain the reason for denial and provide you with the administrative file on request.
You may have as little as 180 days from the date of the denial to file an appeal. However, you cannot go straight to court, although you will get the most objectivity from a judge. First, you have to go back to the same insurance company that denied you. Even though this seems like a waste of time and less than fair, the law requires this step.
The same insurance company that may have stretched to say no in the first place now must admit it made a mistake. While this can happen (and it does occur occasionally), you can usually expect more of the same runaround. The insurance company will come up with the same or new reasons to continue to deny your claim.
You do get something valuable from the insurance company appeals process. Assuming that you participated fully in the process, you will end up with a record that the federal judge will consider at the next step of your case. Once the insurance company turns it down (and we assume they will), the next step is to go to the federal district court. In many respects, this is where your case begins.
When your case gets to federal court, one major limitation is that you cannot build a record from scratch. The federal judge’s function is to review the insurance company’s decision with the record that they had. The law does not allow you to add to the file except in minimal circumstances.
The administrative record for your ERISA appeal will usually include:
Often, you will find out that the insurance company did not give any weight to what your treating physician said, even though they are the ones who saw you in person. They may have their own doctor provide an opinion without even seeing you. Insurance companies have gotten into trouble for this in appeals. You can expect insurance companies to take statements out of context and look for facts that will help them, even if the rest of the record contradicts them.
Do not count on getting a full courtroom trial when you appeal in district court. Your lawyer will write a brief that argues your case, and the judge will consider the record. You will not get to testify. Your appeal is not that kind of trial.
Sometimes, your lawyer may answer questions from a judge in oral arguments. The judge is looking to see whether the insurance company made a mistake in denying you benefits. How much deference they give the insurance company depends on the language of your policy.
No matter the standard of review, wrong insurance company denials that are not rooted in rationality will not pass muster with the judge. If your diagnosis meets the definition of “disabled,” you should qualify for benefits. Insurance companies cannot put a hollow and biased rejection before a judge and expect to get away with it. Certainly, we will point out everything wrong with the insurance company’s decision that will flunk it under any standard of review.
Unfortunately, ERISA is not the most claimant-friendly law, and it gives insurance companies plenty of power. What it does not give them is absolute power. You can always get to court and have a judge review the record. First, you must jump through the insurance company’s hoops in your path. Eventually, you will get your day in court before an objective judge who does not have the same considerations as the self-interested insurance company.
What you need the most is an experienced lawyer who knows the ERISA appeal system. As you saw from the case of the man who fought Sun Life for 15 years, you can expect a battle. These cases can be worth millions of dollars, depending on your age and income before your disability. This is why insurance companies fight these claims tooth and nail.
Unfortunately, this is a case when one of the players also gets to referee part of their own game. An aggressive attorney will look after your interests on an unlevel playing field.
When you need a tough ERISA long-term disability lawyer, J. Price McNamara ERISA Insurance Claim Attorney is here. We know the games that insurance companies play, and we do not let them get away with it. We hold them accountable to get what you legally deserve under your plan. Call us today at (504) 420-6962 or contact us online to learn more about what we can do for you.
This has been a very difficult time for myself and my family. Mr. Mcnamara did his best to be as empathetic and compassionate as possible. He is very knowledgeable and a man of great integrity.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts