{"id":7565,"date":"2020-05-04T14:14:00","date_gmt":"2020-05-04T19:14:00","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7565"},"modified":"2024-01-19T12:28:48","modified_gmt":"2024-01-19T17:28:48","slug":"wilkinson-v-sun-life-sun-life-abused-its-discretion-by-denying-benefits","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/wilkinson-v-sun-life-sun-life-abused-its-discretion-by-denying-benefits\/","title":{"rendered":"Wilkinson v. Sun Life – Sun Life Abused Its Discretion By Denying Benefits"},"content":{"rendered":"

Case Name:\u00a0<\/strong>Wilkinson v. Sun Life and Health Insurance Company, d\/b\/a Sun Life Financial<\/p>\n

Court:\u00a0<\/strong>U.S. Court of Appeals for the Fourth Circuit, on appeal from the U.S. District Court for the Western District of North Carolina.<\/p>\n

Date of Decision:\u00a0<\/strong>January 5, 2017<\/p>\n

Note:\u00a0<\/strong>This case is \u201cUnpublished\u201d. Unpublished opinions are not binding precedent in the Fourth Circuit.<\/p>\n

Type of Claim:\u00a0<\/strong>Long-Term Disability<\/a>\u00a0pursuant to the Employee Retirement Income Security Act of 1974 (\u201cERISA\u201d), 29 U.S.C. \u00a7\u00a7 1001 et seq.<\/a><\/p>\n

Insurance Company:\u00a0<\/strong>Sun Life and Health Insurance Company<\/a>\u00a0(U.S.) (\u201cSun Life\u201d).<\/p>\n

Claimant\u2019s Employer:\u00a0<\/strong>Dolan & Traynor, Inc. (\u201cD&T\u201d).<\/p>\n

Claimant\u2019s Occupation \/ Job Position:\u00a0<\/strong>Vice president<\/a> of sales, operations, and distribution.<\/p>\n

Disabilities:\u00a0<\/strong>Cardiomyopathy<\/a><\/p>\n

Definition of Disability in the Plan\/Policy:\u00a0<\/strong>Importantly, Sun Life\u2019s \u201cassessment of total disability [was] based on one\u2019s occupation [as a vice president] in the national economy, not by the job requirements of a particular employer.\u201d Sun Life claimed that although D&T described Wilkinson\u2019s \u201cjob as heavy duty,\u201d a vice president in the national economy fits \u201ccloser to the light physical demand level.\u201d<\/p>\n

Other Key Definitions in the Plan\/Policy:\u00a0<\/strong>The terms of the Policy limit coverage to \u201cACTIVE FULL-TIME EMPLOYEES WHO SATISFY THE COVERAGE ELIGIBILITY REQUIREMENTS.\u201d The Policy further provides: \u201cYou are an Active Full-time Employee actively at work on any day if on that day you are: . . . performing all of the duties of your job on a Full-time Basis and working on a regular work schedule of at least 30 hours per week . . . .\u201d<\/p>\n

Benefits Paid?\u00a0<\/strong>After approving the benefits claim under a policy that Sun Life issued to Wilkinson\u2019s former employer, Sun Life terminated benefits on the grounds that Wilkinson was not an active full-time employee when the policy took effect.<\/p>\n

Basis For Denial \/ Termination of Benefits:\u00a0<\/strong>Sun Life sent Wilkinson the first denial letter on July 29, 2008, stating that he no longer qualified for long-term disability benefits. This denial letter noted that Sun Life had recently learned of the New Jersey lawsuit and that Sun Life believed Wilkinson may have resigned from D&T because of disagreements with the partners rather than for medical reasons. Regardless, Sun Life justified the first denial because it \u201cconcluded that there was no medical evidence to continue to support [Wilkinson\u2019s] claimed restrictions and limitations.\u201d<\/p>\n

Sun Life sent Wilkinson a second denial letter on May 13, 2009. This letter noted that a physician described Wilkinson\u2019s \u201ccardiac status as causing only slight limitation in physical activity.\u201d The letter also stated a functional capacity evaluation revealed that Wilkinson \u201chad the capacity to perform his occupation as it is typically performed in the national economy.\u201d Nevertheless, Sun Life expressly stated that it was \u201cnot addressing any question of Disability at this time,\u201d and that it was denying coverage on different grounds. Sun Life found Wilkinson ineligible for coverage under the Policy because, in its view, two declarations filed in the New Jersey Lawsuit indicated Wilkinson \u201cwas not meeting the requirements of an Active Full-time Employee at the time coverage became effective . . . on May 1, 2004.\u201d Thus, five years after Wilkinson left D&T, Sun Life asserted a new theory for why Wilkinson did not qualify for coverage.<\/p>\n

Sun Life sent Wilkinson a third denial letter on July 12, 2010. At that point, the sole issue was whether Wilkinson was \u201cperforming all the duties of [his] job on a Full-time Basis and working on a regular work schedule of at least 30 hours per week\u201d when the Policy took effect.<\/p>\n

Wilkinson filed suit in Federal Court.<\/p>\n

Ultimately, the district court found that Wilkinson met his burden to show that he was covered under the Policy and that Sun Life abused its discretion by denying benefits.<\/p>\n

Procedural history:\u00a0<\/strong>On cross-motions for summary judgment, the district court granted judgment in favor of Wilkinson.<\/p>\n

Key Physician Opinions:\u00a0<\/strong>As part of Wilkinson\u2019s administrative appeal, a physician hired by Sun Life provided medical findings indicating that \u201cWilkinson would be precluded from the duties of his \u2018Regular Occupation\u2019 and was \u2018Totally Disabled.\u2019\u201d This finding essentially foreclosed Sun Life\u2019s denial of benefits based on medical grounds.<\/p>\n

Issues:\u00a0<\/strong>The key issue presented is whether the district court erred in holding that Sun Life, the administrator of an employee welfare benefit plan governed by ERISA, abused its discretion when it terminated Wilkinson\u2019s benefits.<\/p>\n

Holdings:\u00a0<\/strong>The Fourth Circuit held that Sun Life abused its discretion when it terminated Wilkinson\u2019s benefits because he provided sufficient evidence to support his eligibility for coverage and because Sun Life\u2019s decision to terminate benefits was not the result of a principled reasoning process and not supported by substantial evidence. The Fourth Circuit, therefore, affirmed the district court\u2019s decision.<\/p>\n

The facts relevant to this appeal are those probative of whether Wilkinson worked at least 30 hours per week as an active employee on May 1, 2004, when the policy at issue took effect.<\/p>\n

Sun Life frames Wilkinson\u2019s evidence as relevant to the time when he received compensation, not when he actually worked. Nevertheless, Wilkinson met his burden to provide sufficient evidence of his eligibility for coverage when the Policy took effect on May 1, 2004 (i.e., by providing evidence that he worked at least 30 hours per week). First, the FMLA Form indicates that D&T expected Wilkinson to take leave beginning \u201con or about May 10, 2004.\u201d Second, a Sun Life letter acknowledges: \u201c[D&T] indicated May 7, 2004 as the last day that Mr. Wilkinson worked and that his work schedule at the time of the disability was five days per week, 8 hours per day.\u201d Third, notes dated August 2004 from Wilkinson\u2019s physician lists May 7, 2004, as the \u201cDate patient-ceased work because of disability.\u201d Fourth, an April 2004 email from Wilkinson to his business partners \u201cexpressed [his] desire to work 30\u201340 hours a week,\u201d which at least implies his business partners wanted him to work more than 30 hours. Fifth, Wilkinson filed an unrelated insurance application with Security Mutual, listing May 7, 2004, as the \u201cDate [he] stopped work.\u201d<\/p>\n

Summary:\u00a0<\/strong>In sum, several Booth factors<\/a> show that Sun Life abused its discretion, including (1) the \u201clanguage of the plan\u201d; (2) the \u201cadequacy of the materials considered\u201d; (3) Sun Life\u2019s \u201cdecision-making process\u201d; and (4) the indicators that Sun Life\u2019s conflict of interest played a role in its review process. See Booth, 201 F.3d at 342\u201343. Because Sun Life\u2019s coverage determination was not reasoned and principled and not supported by substantial evidence, the Court holds that Sun Life abused its discretion.<\/p>\n

\n

Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.<\/p>\n

Here is a PDF copy of the decision: Wilkinson v. Sun Life<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

The Fourth Circuit held that Sun Life abused its discretion when it terminated Wilkinson\u2019s benefits because he provided sufficient evidence to support his eligibility for coverage and because Sun Life\u2019s decision to terminate benefits was not the result of a principled reasoning process and not supported by substantial evidence. The Fourth Circuit, therefore, affirmed the district court\u2019s decision.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[263],"_links":{"self":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7565"}],"collection":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/comments?post=7565"}],"version-history":[{"count":0,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7565\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/media?parent=7565"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/categories?post=7565"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/tags?post=7565"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}