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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Business Law
Satisfied Customers: 111527
Experience:  All corporate law, including non-profits and charitable fraternal organizations.
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Have been off work since Aug 24 FMLA papers signed delivered

Customer Question

Have been off work since Aug 24 FMLA papers signed delivered to Sun Life Ins have ST and LT disability thru work.By time short term paperwork was getting done long term kicked in Well do this day no cks. They keep saying need more medical records etc. etc Case worker will not return calls since longterm can't pay til ST makes a decision I'm broke as a skunk. Sing then have had to be let go because Co. Dr said am not able to perform job duties as before. And still no money Still Pending . Have filed for SSD but I want money owed to me. Did some research on Sun Life not impressed guess they don't like to pay. Well am going to get lawyer as i he been calling last 4 business days to see if received documents from last two drs no response. They wait til their 30 days is about up send me letter stating need more time. Their decision is to be made this time by 18th. What do you think are you familiar with this multi billion $ Co
Submitted: 9 months ago.
Category: Business Law
Expert:  Law Educator, Esq. replied 9 months ago.
Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.
Under FMLA, your protection ended after 12 weeks. At this point you have a breach of contract claim with the insurer. If you have provided them the medical records and they are still claiming they need more, you need to send them a written appeal first informing them you supplied all medical records on your case and their continued denial is breach of contract in bad faith and that if they do not pay on the claim, you will file a complaint with the state insurance commissioner and pursue legal action.
A bad faith insurance claim can allow you to recover 2-3 times the amount of money actually due, plus your attorney's fees. So if they continue to refuse to pay after you send them a letter demanding payment, your final option is a complaint to the insurance commissioner AND filing suit against them with a local insurance law attorney for bad faith breach of contract.
Wait until the 18th and if they do not decide then and want more time, then send the letter I said above and give them 5 days to respond and if they refuse at that point proceed with the other options.
Customer: replied 9 months ago.
Received letter stating need more time but received phone call earlier that day from my caseworker shock that they should have their mind made up Friday or Monday now she's telling me they're having problems making a decision if I actually have a case for short term disability I have chronic myeloid leukemia Philadelphia chromosome sorry have been on chemo pills for going on three years and the side effects are muscle cramps which I get all the time in there so bad that I have to take my shoes off when driving but they respected my back and that's why I was off work it's a proven fact when you google Gleevec what the side effects are but they're saying that that should not cause my back pain they did an MRI they sent me to pain management for injections treating me for a bulging disc which I did not have went to a chiro he couldn't help me still going to physical therapy I've got a mass of muscle knotted up in my lower back that standing in one spot with limited movement the muscle contraction constantly pinching a nerve but they don't think that's good enough so I think that's what the holdup is they're going to tell me I don't have a case even though my company Dr did fitness to return to work physical and told me I can't do it I cannot take my shoes off at work number one he said all that got to do is Google this and it's a proven fact of the side effects so no matter what I'm going to have to end up getting a lawyer to fight him cuz I got a feeling they're going to deny me but still there asking for more records well they finally got them all I guess I should go back to square one where they misdiagnosed me and I had to go through two sets of injections in my back for something I didn't have and my cancer doctor was the one that referred me to have the injections so I see a specialist and he said i shouldn't have gone through that there was nothing in the MRI to suggest a bulging disc so somebody screwed up so now I don't know what to do do I wait a couple of days to see if they made their decision where do I go for it what do you suggest
Expert:  Law Educator, Esq. replied 9 months ago.
Thank you for your reply.
At this point, you need to consider filing a claim for breach of contract in bad faith. You need to send them a letter first, like I said above, informing them that your condition as supported by all of the medical records you have provided qualifies you for coverage and their delay and continued denial of coverage and failure to make a determination in a reasonable time is in bad faith and if they do not make the decision approving your benefits you will pursue a bad faith breach of contract claim against them in court.
Give them 5 days in your letter to notify you of the approval and if they do not respond in that time, then you do need to get a local attorney and pursue the suit against them.

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