Form Letter to Attending Physician/Specialist

File No. 

 

(date)

 

To Whom It May Concern:

 

                    Brother/Sister XX has asked me to intervene on his/her behalf concerning a decision taken by Sun Life Assurance Company of Canada to deny his/her claim for disability insurance benefits.  Brother/Sister XX has recently provided me with related medical and non-medical documentation involving his/her case.  I am writing to you to have this situation resolved in as expeditious a manner as possible.

In the last correspondence to Brother/Sister XX concerning his/her claim (Date), Sun Life suggested that his/her case would be reviewed again upon receipt of additional objective medical evidence.  My past experience with the processing of disability insurance claims indicates that the provision of detailed information on the following will lead to the successful adjudication of his/her claim:

 

1.   the nature, extent and severity of the disability condition (this would include references to significant symptoms where a diagnosis has yet to be determined);

2.   the restrictions the disabling condition impose on the claimant in terms of his/her daily activities (e.g. ability to do household chores, ability to interact with others in social settings, participation in any sports or hobbies, attempts at rehabilitative employment or any alternate employment, limitations in walking, sitting, standing or tasks requiring extended periods of concentration, etc.);

3.   how the restrictions identified above prevent the claimant from performing each and every duty of his/her regular occupation or employement/a commensurate occupation;

4.   the prognosis for the disabling condition;

5. the current treatment being undertaken by the claimant (e.g. frequency of visits for medical attention, current medical program, all prescribed medication along with respective doses, diet, exercise program, therapies, etc.);

6.     any available supplementary documentation, such as consultation notes, assessments, GAF scores and test results which would illuminate on the decline and/or deterioration in Brother/Sister     XX’s  medical condition.

For your information, at the moment of becoming disabled, Brother/Sister XX was employed at Department/Agency as a Occupation (Classification) and earning approximately $XX,000 per annum.

The existing disability insurance contract includes the following definition of “Totally Disabled”:

          “An Employee is Totally Disabled if he is in a continuous state of incapacity due to Illness which

1.     while it continues during the Elimination Period and the following 24 months, prevents the Employee from performing each and every duty of his regular occupation or Employment.

Loss or suspension of a license, due to Illness unrelated to alcoholism or drug addiction, which such Employee requires to carry out his regular occupation, will be considered Total Disability during the Elimination Period and the following 24 months, but only while such license continues to be withheld for the same reason.

2.     while it continues thereafter, prevents the Employee from engaging in any Commensurate Occupation for which he is or becomes reasonably qualified by education, training or experience.

In no event, however, will an Employee be considered Totally Disabled if during any period he does not take part or co-operate in a Reasonable And Customary Treatment Program.

          The term “Commensurate Occupation” is further defined as:

“An occupation for which the current salary or current rate of pay is not less than 66 2/3% of the then current salary for the Employee’s own regular occupation.”

                    In an effort to assist Brother/Sister XX in the approval of his/her disability benefits I would suggest that, as the attending physician/specialist in this case, you provide Sun Life with the information as identified above, attesting to Brother/Sister XX’s continuous incapacity to perform the duties of each and every duty of his/her regular occupation or employment/a commensurate occupation beyond Date.

                    Would you please have all of the above documentation and information sent to the following address or Secure Facsimile Number:

                                        Federal D.I. Plan

                                        Sun Life Assurance Company of Canada

                                        P. O. Box 12500, Station CV,

                                        Montreal, Quebec

                                        H3C 5T6

 

                                        Secure Facsimile No. 1-866-639-7849

 

In your correspondence, please cite Brother/Sister XX’s Contract # LTD 12500 and Certificate No. #CG#######.

 

                   I can assure you that should Sun Life fail to provide approval for Brother/Sister XX following receipt of the specified information above, I will have his/her case presented to the Disability Insurance Plan Board of Management forthwith. This latter Board serves as an independent forum for review of Sun Life decisions involving denial of disability benefits to individual claimants. 

 

                    Please note I also understand that, as a health care professional, you have a very busy and hectic schedule and the effort to provide the information required in this case can be a time-consuming and tedious affair.  However, I am convinced, as I believe you are, that Brother/Sister XX is legitimately entitled to disability insurance benefits and deserves appropriate representation.

 

                    Please be advised that any cost associated with the provision of this information is the responsibility of Brother/Sister XX.

 

                    I trust you will find the above acceptable and should you have further questions or require any clarifications, please do not hesitate to contact me at

(XXX) XXX-XXXX.

                                                  Sincerely,

                                                

                                                  Local Union Officer

                                                  Local Union Position

Topics: 

September 22, 2013
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