In a recent decision, Delisle v Sun Life, the 6th Circuit Court of Appeals affirmed a decision requiring Long Term Disability Insurer Sun-Life to pay disability benefits even though 6 of its hired physicians supported its decision to terminate benefits.
In finding that Sun-Life’s decision was arbitrary and capricious the Court recognized that 5 of the 6 physicians were “under regular contract with Sun Life” and that such physician reviewers may have an incentive to make a finding of not disabled in order to save their employers money and preserve their own consulting arrangements.
The Court also pointed out Sun Life’s failure to attach any weight to the fact that plaintiff was awarded SSD benefits. In fact, Sun Life failed to even acknowledge the award in any of the three denial letters.
The Court also recognized the bias injected into the case by Sun Life’s employees who simply told the reviewing physicians that the plaintiff had been “terminated for cause” when, in fact, it appears she had been terminated because she was unable to do her job due to her medical condition. (Which is the purpose of having disability insurance!) The Court found that the “bald asserion that she was fired “for cause” gave the medical reviewers incomplete and potentially prejudcial information which suggests “procedural unreasonableness.”
The Court also took issue with the fact that Sun Life’s paid medical reviewers largely agreed with the treating physician’s diagnosis but simply discounted the effect they had on her ability to work.
This case presents a good example of the inherent bias faced by many individuals making a claim for long term disability benefits. The insurance company hires the same doctors over and over who almost never find anyone disabled. Even when there is overwhelming evidence in the medical records of a claimant’s condition, they simply discount the effect the condition has on the claimant’s ability to work. The sad part is that given the current limited review conducted by most court’s, many time this is enough to prevent the claimant from getting benefits. Until the ERISA statute is changed, this unbalanced approach is a license for disability insurer’s to put profit over people.