Court: United States District Court, Eastern District of Missouri
Insurance Carrier: Sun Life Assurance Company of Canada
Claimant’s Employer: Retina Consultants, LTD
Claimant’s Occupation: Ophthalmic Technician
Disclaimer: Please note that this claim was not handled by the Ortiz Law Firm. It is summarized here for educational purposes.
Background of the Case
Taylor Ziegler, a former ophthalmic technician at Retina Consultants, LTD, began experiencing severe pain, fatigue, and other symptoms that her doctors attributed to immune system disorders, including lupus and Sjogren’s syndrome. As her condition worsened, she applied for long-term disability (LTD) benefits under her employer’s ERISA-governed welfare plan, which was insured and administered by Sun Life Assurance Company of Canada.
Sun Life initially approved Ziegler’s LTD claim, but only for a limited period, after which further evidence was required to continue benefits. After reviewing the medical records, Sun Life denied Ziegler’s claim, concluding that the medical evidence purportedly did not support her inability to work beyond September 17, 2019. Ziegler appealed this decision, but Sun Life upheld the denial based on additional medical reviews.
Sun Life’s Reasons for Denial
Sun Life relied on the opinions of three board-certified rheumatologists who reviewed Ziegler’s medical records. These independent reviewers found that her symptoms lacked sufficient objective evidence to confirm a disabling condition. While her treating physician, Dr. Richard DiValerio, diagnosed lupus and related conditions, Sun Life’s medical reviewers concluded that the records did not support the severity of limitations that would prevent her from performing her job.
Key findings of the medical reviews included:
- Lack of objective evidence to support lupus or inflammatory arthritis.
- No significant physical examination findings to support severe limitations.
- An assessment that Ziegler’s primary symptoms—pain and fatigue—were consistent with fibromyalgia, which they considered chronic but not disabling.
RELATED POST: Understanding Sun Life’s Independent Physician Reviews
Arguments and Court Decision
Ziegler challenged Sun Life’s decision on two main grounds:
- She argued that Sun Life improperly required objective evidence when her conditions were inherently difficult to measure objectively.
- She claimed that her pain and fatigue caused functional limitations that the insurance company ignored.
The court rejected both arguments, emphasizing that the plan required “proof” of disability, and that Sun Life had the discretion to evaluate the evidence submitted. The court found that Sun Life’s reliance on independent medical opinions was reasonable because ERISA administrators are not required to defer to treating physicians. Because several reviewing physicians found no compelling medical evidence to support continued disability, the court held that Sun Life did not abuse its discretion in denying benefits.
Implications for Disability Claimants
This case highlights the importance of objective medical evidence in ERISA disability claims. While conditions such as lupus and fibromyalgia can cause significant impairment, claimants must provide clear medical documentation to support their functional limitations.
If you or a loved one has had a long-term disability claim denied due to a lack of objective evidence or conflicting medical opinions, the Ortiz Law Firm can help. We specialize in ERISA disability appeals and will fight to get you the benefits you deserve. Contact us today for a free case evaluation.
Here is a PDF copy of the decision: Ziegler v. Sun Life Assurance Company of Canada
