Our client, a successful and young professor at a university, initially came to us to appeal her denied short term disability insurance claim. Her ERISA disability policy was through her employment. She was unable to return to work, but her claim had been denied, leaving her with few options. She was suffering from Chronic Fatigue Syndrome (CFE/ME) and could not even engage in simple tasks, much less continue to work.
We took on her appeal and shared our confidence in the ability to overturn the claim denial. We succeeded and were able to navigate her claim for her short term claim and provide support to allow her to also transition into long term disability.
She was paid for a period of time, until Sun Life terminated the claim at the transition definition from “own occupation” to “any occupation.” To secure this twisted result, Sun Life relied upon limited surveillance and a paper reviewing physician’s opinion, and then coupled that with a deficient vocational review, which did not account for any of our client’s physical or cognitive limitations.
Our client was a Professor in her 30s whose work required significant cognitive challenges and was also physical in nature: she needed to be able to stand for extended periods of time. When she first began suffering symptoms, like most claimants, she was unsure of the diagnosis, and spent time, money and energy seeking a variety of tests in the hope that she would be able to determine what was causing her symptoms, especially the fatigue.
When we engaged with the client, we were able to guide her client toward the necessary and appropriate testing to help demonstrate impairment in a CFS/ME claim. Our client was examined and evaluated for CPET (Cardio Pulmonary Exercise Testing), by Dr. Betsy Keller, from Ithaca College, one of a small handful of facilities who produce this testing, which has been held by courts to be the “gold standard” for providing evidence of impairment in CFS/ME claims. This two-day exercise test yields results which translate into one’s level of functionality and is a data driven analysis, making it difficult to challenge.
We also secured cognitive testing, which demonstrated impairments in functionality that we were able to tease out to support her inability to engage in any occupation on any sustained or predictable basis. We also were able to demonstrate that the deficits were not mental health or depression related, but due to her lack of energy, focus and physical functionality.
Using these powerful test results and objective findings to support impairment, we worked with our client’s doctors to develop responsive information and documentation to support the claim and rebut the underlying medical support for Sun Life’s position.
We also developed a powerful statement from our client describing the impact of her conditions upon her career, and upon her ability to engage in any sustained activity. We worked to rebut the limited surveillance, arguing that it supported her claim of impairment, rather than any level of functionality. Collectively, this powerful appeal evidence was submitted in support of further benefits.
Armed with this evidence and our advocacy, we were able to undercut Sun Life’s medical and vocational reviews, demonstrating that the evidence upon which its decision was made was utterly lacking in quality. Undercutting the claim decision, like the foundation of a home, forced the house to fold.
Despite efforts to diffuse the power of our appeal submission, Sun Life ultimately relented and determined that our client did, in fact, meet the definition of disability for any occupation, and her long-term disability insurance benefits have been reinstated. She has now been paid to current status and remains on claim and under our guidance.