Can Your Insurer Deny Benefits After Years of Paying Out Claims? A Case Study
You’ve been receiving benefits for years—can your insurance company just change its mind and decide to suddenly deny benefits? That’s what happened in the case of Roehr v. Sun Life.[1] Dr. Roehr was a practicing, board-certified anesthesiologist who began experiencing intermittent tremors in his hands and fingers in 2004. While he was initially concerned that he had Parkinson’s disease, due to a family history, subsequent examinations by neurologists indicated that it was not Parkinson’s disease, rather he was diagnosed as having “a tremor of unclear etiology.”
In October 2006, Dr. Roehr stopped practicing out of concern for patient safety and filed a claim under the “own occupation” provision of his Sun Life policy. While none of the neurologists Dr. Roehr had seen were able to give a specific diagnosis related to his tremors, he continued to receive follow up care from his primary care physician, and Sun Life paid benefits for the next ten years. This was the case even though his primary care physician’s records failed to sometimes note an observation of tremors (usually when the record was dealing with a separate medical issue). Over these ten years, Sun Life occasionally requested medical updates from Dr. Roehr’s primary care physician.
In 2017, Sun Life retained a neurologist to review Dr. Roehr’s claim. The neurologist confirmed that Dr. Roehr did not have Parkinson’s disease and questioned whether Dr. Roehr’s condition might not have improved, based on the available medical records. Sun Life subsequently terminated Dr. Roehr’s benefits and upheld this decision on appeal in 2018.
In its review, the court acknowledged that review of the case was complicated by the facts that Dr. Roehr’s tremors were unexplained, his physician had observed temporary improvement in his condition, and he had not completed neuropsychological or other testing that had been suggested early on by a neurologist. However, the court ultimately sided with Dr. Roehr, indicating that Sun Life had not conducted an assessment by a neurologist/movement disorder specialist, even though their reviewing neurologist had recommended it. Further, the court explained that “Sun Life relied on virtually the same medical records for a decade and has pointed to no information available to it that altered in some significant way its previous decision to pay benefits.”
While Dr. Roehr was successful, the case had to proceed to costly litigation in order for him to prevail. The case is an example of why it is important to have carefully detailed medical records that clearly document a disability and stands as an important reminder that insurance companies are often looking for ways to deny claims, even those they have been paying out for years.
If you are on claim and feel that your insurance company has begun questioning your claim, please feel free to reach out to one of our attorneys directly.
[1] Roehr v. Sun Life Assurance Co., No. 21-1559, 2021 WL 6109959 (8th Cir. Dec. 27, 2021)
