District Court Finds Sun Life Did Not Abuse Its Discretion in Denying ERISA Long Term Disability Benefit Claim for Claimant with Autoimmune Disorders

In Ziegler v. Sun Life Assurance Company of Canada, No. 4:22-CV-01115-SRC, 2024 WL 3874529 (E.D. Mo. Aug. 19, 2024), Missouri Eastern District Chief Judge Stephen R. Clark granted Sun Life’s motion for summary judgment finding that Sun Life did not abuse its discretion in terminating Plaintiff’s long-term disability benefits based on the opinions of three peer reviewers and the absence of objective evidence supporting ongoing disability. The court concluded that the medical information did not support restrictions and/or limitations that would preclude Plaintiff from performing the material and substantial duties of her own occupation.

Shortly after returning from maternity leave, Plaintiff, who was 27 years old and had previously been diagnosed with lupus, began having pain in her joints which she hadn’t experienced for years. Her treating physician wrote that Plaintiff was disabled due to systemic lupus erythematosus and secondary diagnoses of inflammatory polyarthropathy and Sjogren’s syndrome, with symptoms of diffuse joint and muscle pain, weakness, fatigue, and brain fog. Plaintiff’s physician opined that she was unable to use her hand for simple grasping, firm grasping, fine manipulation, or keyboarding and would only be occasionally able to walk, sit, or stand. Her doctor further opined that Plaintiff was limited to sedentary-capacity work and no recovery was expected.

Sun Life approved Plaintiff’s LTD claim for a limited period while it sought and reviewed additional information. However, Sun Life denied further LTD benefits after a peer review by a board-certified rheumatologist concluded that Plaintiff’s exams did not document any typical manifestations normally associated with lupus, including dry mouth, dry eyes, mouth sores/alopecia/lupus rashes, joint swelling, or deformity, and there was no internal organ involvement or organ damage (such as lupus nephritis/kidney disease, cardiopulmonary disease, or CNS disease). The peer reviewer also found no objective evidence for inflammatory arthritis on any exam, lab, diagnostic, or imaging, and the only significant musculoskeletal finding was decreased hand grip. Sun Life concluded there was no evidence in the documentation to support the severe restrictions and limitations promulgated by Plaintiff’s physician or that “this young lady should be incapacitated for the rest of her life.”

On appeal, Plaintiff provided additional medical records, including a functional capacity questionnaire completed by her treating physician, who reported that clinical findings, laboratory and test results, and other symptoms showed signs of malar rash (over the cheeks), discoid rash, photosensitivity, and oral ulcers. A second peer reviewer noted that there were no objective findings in the medical records to support a lupus diagnosis – no documentation of malar rash, oral ulcers, or joint swelling, or any swelling, deformity of weakness. The peer reviewer found no evidence to support Plaintiff’s alleged limitations in the areas of fine manipulation, grasping, overhead reaching, stair climbing, or stooping or crouching. The peer reviewer opined that the records were consistent with claims of pain and fatigue and felt they stemmed from fibromyalgia, but that the condition was chronic and did not support medical restrictions precluding full-time work. After Plaintiff questioned the results of the second peer review, Sun Life ordered a third peer review that similarly noted the discrepancy between the treating provider’s functional capacity questionnaire and the contemporaneous medical notes. Ultimately, Sun Life upheld the denial on appeal, and the instant lawsuit followed.

Under an abuse of discretion standard, the Court found that Sun Life’s determination was not unreasonable. Citing the Eighth Circuit decision in Pralutsky v. Metro. Life Ins. Co.,435 F.3d 833, 839 (8th Cir. 2006), the Court found that the plan provision requiring Plaintiff to “provide proof that you continue to be Totally or Partially Disabled” was reasonably interpreted by Sun Life to require objective evidence of disability. The Court also concluded that Sun Life had discretion to weigh conflicting evidence of the diagnosis and severity of fibromyalgia. And its decision to deny benefits based upon its acceptance of the opinions of its reviewing physicians over the conflicting opinions of Plaintiff’s treating providers was not arbitrary or capricious.

If MetLife or your insurer has denied or otherwise limited your disability insurance claim, contact us for assistance.