Healthcare Coordinator Wins New York Life LTD Insurance Appeal for Chronic Pain

Our client, Ms. G, formerly worked as a Healthcare Coordinator for a large regional healthcare provider. For many years Ms. G suffered from chronic debilitating effects of multiple physical conditions and ailments, including, among other conditions, Intractable Pain, Chronic Venous Insufficiency, which left her with debilitating physical and cognitive impairments. Ms. G was unwilling to give up her career and worked as long as she possibly could. Finally, as a result of these conditions and the restrictions and limitations associated with them, Ms. G stopped working completely in March 2017 and applied for disability benefits; first under her employer’s Short Term Disability (STD) Policy, then continuing under its Group LTD Policy, both of which were administered and funded by New York Life.

New York Life found Ms. G to be totally disabled – i.e., unable to perform the material duties of her Regular Job – and approved her STD claim through the maximum benefit period. With the expiration of the STD benefits Ms. G’s claim was submitted for continued payment under her employer’s LTD Policy – i.e., unable to perform the material duties of her Regular Occupation. After paying her LTD benefits for approximately 10 months Ms. G was informed that her LTD benefits were denied because New York Life determined that “[her] medically supported activity restrictions are consistent with the physical demands of [her] own light occupation.” After receiving the denial, Ms. G contacted Dell Disability Lawyers and discussed her case with Attorney Jay Symonds, who identified several significant issues in New York Life’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. G’s ERISA appeal with the assistance of his appeal team.

The appeal addressed all of Guardian’s short-comings and reasons for denial. First, a simple review of New York Life’s purported medical reviews confirmed that the opinions were largely speculative, contradicted by the medical evidence and did not constitute a reasonable basis on which New York Life could deny Ms. G’s continued LTD benefit. Despite Ms. G’s multiple, complex medical conditions, the medical reviews consisted of 1 page, unchanged medical summaries that confirmed Ms. G had not shown any significant improvements or changes in her conditions. New York Life’s medical reviewers offered no rationale or explanation for their disagreement with and disregard of Ms. G’s own medical providers opinions. What’s more, New York Life’s primary medical reviewer offered significant, contradictory statements regarding the severity of her conditions and her alleged functionality. For example, despite acknowledging that Ms. G suffered from chronic lower extremity edema/lymphedema that limited her ability to perform physical activity and conceding that her chronic bilateral lower extremity conditions would limit “prolonged” sedentary work, the reviewer then claimed that she could perform “frequent” sitting, which means sitting 6 hours or more in an 8 hour workday.

Next, it was clear that New York Life’s vocational reviewers did not understand what is required of Ms. G’s occupation as a Healthcare Coordinator. Although New York Life confirmed that Ms. G’s occupation was considered “light” occupation it ignored the pertinent walking and standing requirements of Ms. G’s occupation, which she was incapable of performing due to severe swelling and pain in her lower extremities that required consistent bandaging and lymphatic manual massages. Her conditions also required that she keep both legs elevated as often possible. Such functional restrictions were clearly not consistent with the walking and standing requirements of her occupation yet were ignored by New York Life.

Finally, because New York Life did not request an examination of Ms. G, and to provide additional objective evidence of her functional limitations, Ms. G underwent an independent Functional Capacity Examination (FCE). The results of the FCE confirmed that Ms. G had less than sedentary functional capabilities. Specifically, the FCE concluded that she suffered impairments with sitting, standing, walking, squatting, kneeling, and climbing. She had difficulties with sustained activity in any position and was unable to functionally grip, grasp, lift or use her hands for any fine motor tasks. She demonstrated gait deviations that would prevent her from being able to safely lift, carry, push, or pull. Her positional tolerances for walking, standing, and sitting were accompanied by fatigue, bilateral hand pain, low back pain, neck pain, and weakness. The FCE also established that Ms. G ambulated with a slow antalgic gait and used a rolling walker. She was unable to stand independently in a single stance. Importantly, the validity testing associated with the FCE confirmed that the results were an accurate representation of Ms. G’s functional abilities.

Just 7 weeks after filing his appeal, and after reviewing hundreds of pages of exhibits and medical records, New York Life overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. G’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that New York Life will not terminate his benefits again. Feel free to call our disability insurance attorneys for a free consultation regarding any matter relevant to your disability claim.