In Vicki Young v. Sun Life and Health Insurance Company, plaintiff Young, a mortgage broker, was initially granted disability benefits in September 2010 based on her diagnosis of fibromyalgia. The initial two years of her disability were based on her inability to perform the essentially duties of her own occupation.

After two years, Sun Life continued her long term disability (LTD) benefits on the grounds that she did not have the ability to perform the job duties of any occupation for which she was qualified. Suddenly, in 2015, Sun Life terminated her benefits, stating she was no longer disabled under the “any occupation” standard. Young’s administrative appeal was denied and she filed this ERISA lawsuit in the U.S. District Court for the Eastern District of California.

The Court agreed with Young that Sun Life abused its discretion in terminating her benefits and ordered her LTD benefits reinstated retroactively to the date Sun Life terminated them. The Court found quite a few errors on the part of Sun Life to justify its finding that the insurer had abused its discretion. Plus, a clear conflict of interest on the part of Sun Life as both the one to evaluate the disability claim as well as the one to pay benefits caused the Court to review the case with “an increased level of skepticism.”

Requiring Objective Medical Evidence for Fibromyalgia is an Abuse of Discretion

The Court cited precedent supporting the finding that there are some conditions, like fibromyalgia, for which there is no objective evidence. Plus, Sun Life “never explained what evidence it needed from Young before terminating her LTD benefits and this further illustrates an abuse of discretion.”

Selected Review and Interpretation of Medical Evidence

Sun Life reviewed medical records, reports of its own paid reviewing physicians, reports of independent medical exams (IMEs), but even in doing so, it discounted evidence supporting Young’s LTD claim and gave credence only to those reports that concluded she could work in some occupation.

After reviewing each medical report in detail, the Court concluded: “Sun Life’s decision to terminate Young’s LTD benefits was not supported by substantial evidence, and its review was not ‘full and fair’ as required by law. 29 U.S.C. § 1133(2). Given the totality of the record, viewed through the lens of the standard of review, the Court finds that the Defendant abused its discretion when it terminated Plaintiff’s long-term disability benefits.”

The Remedy

The Court specifically noted that the remedy is different for a Plaintiff like Young, who had her benefits terminated, than it is the remedy for a plaintiff who has a claim for benefits denied. Accordingly, the Court ordered the Plaintiff’s LTD benefits reinstated, “retroactive to the date upon which [Sun Life] ceased paying such benefits.”

If you are struggling with your disability insurer concerning your claim for a disabling condition for which there is no objective medical evidence, contact one of our disability attorney at Dell & Schaefer for a free case evaluation. We can assist with any disability claim and answer any of your questions.