“Green V. Sun Life Assurance Company”
“Green v. Sun Life Assurance Company”
2016 U. S. Dist. LEXIS 28419 (N. D. Ill., March 7, 2016)
Ms. Green was formerly employed by Daiichi Sankyo, Inc., as a pharmaceutical representative. She was being treated for occipital neuralgia and neck pain, as well as depression and anxiety. Ms. Green filed a claim with Daiichi Sankyo’s long-term disability plan, which was funded and administered by Sun Life. Sun Life denied Ms. Green’s claim for long-term disability benefits. Ms. Green appealed the denial. While the appeal was pending, the Social Security Administration issued its determination that Ms. Green was disabled under the SSA’s rules. Without regard to the SSA claim file and without contacting Ms. Green’s then attorney to obtain the SSA determination, Sun Life denied Ms. Green’s appeal, reasoning that she had not been disabled throughout the entire elimination period because, according to Sun Life and its reviewing physicians, Ms. Green had no restrictions from March 3 through April 2, 2012. Ms. Green then hired us to file a lawsuit.
The Court found that there was an absence of evidence in the record to support Sun Life’s conclusion on appeal that Ms. Green had no restrictions from March 3 through April 2, 2012. Sun Life conceded that a pharmaceutical sales representative’s primary duty was to meet with physicians in order to promote pharmaceutical products and persuade them to increase prescriptions of promoted products. The Court explained that it was difficult to see how Ms. Green could have performed those duties given her physician’s assessment of her psychological impairments. The Court reasoned that Sun Life concluded that Ms. Green had no restrictions from March 3 through April 2, 2012, without the benefit of reviewing the SSA claim file or the SSA ALJ’s determination. The Court explained that Sun Life failed to explain why it decided the appeal without the SSA claim file or the SSA determination. Under the SSA’s own rules, no benefits would have been awarded to Ms. Green unless she could perform no job in the national economy, considering her age, education, and work experience. In addition, under the SSA’s rules, the impairment must have lasted or will last for a year or more. The Court explained that Sun Life’s failure to explain its reasons for disagreeing with the ALJ’s determination rendered its denial arbitrary and capricious, particularly given the structural conflict of interest at play.
The Court further explained that the record required further development on all fronts. A remand would enable Sun Life to determine whether the combined effects of Ms. Green’s physical and psychological impairments, as well as the medications used to treat them, caused her to be totally disabled during the time period in question. After reviewing the SSA claim file and the ALJ’s rationale, Sun Life might have determined that the SSA got it right. If Sun Life disagreed with the SSA ALJ’s rationale and the underlying bases, Sun Life would need to explain why it reached a different conclusion.
After the remand, the case settled.