Estes Express Diesel Mechanic Wins New York Life Disability Appeal After Prior Law Firm Sucked

Following a denial of his claim for Long Term Disability (LTD) benefits, our client came to us almost 7 months after he received an April 29, 2021 denial letter. Prior to contacting us, he had taken no action to challenge this denial and no administrative appeal had yet been filed. As his claim is governed by the Employee Retirement Income Security Act (ERISA), historically his delay in filing a timely appeal would be catastrophic to his claim as ERISA mandates that a denied claim must be appealed within 180 days.  Additionally, ERISA states that if you don’t file an administrative appeal, then you lose your rights to ever file a lawsuit.

However, as the world was suffering through a pandemic, the Department of Labor (DOL) mandated that disability insurance companies allow additional time for claimants to file their appeals. Under the most recent guidance provided by the DOL, one of the extensions allows that the 180-day period to file an appeal begins to run one year from the date of denial letter (but know that there are other parameters as well that may impact the timing of other claims). Please be cautioned that by the time you are reading this article or watching this video, these allowed extensions may have ended or may be ending so it is always advisable to file this appeal within the normal 180 day deadline.

For our client’s claim, despite him failing to appeal within the 180 day window, his claim was saved by the allowed extension due to the pandemic.

Employment History

Prior to becoming disabled, our client worked as a Diesel Fleet Mechanic for Estes Express Lines. Estes Express Lines is a well-known and long-established freight transportation company in North America.  You have likely seen their trucks on the road. Our client kept theses trucks on the road and is job is considered a Heavy Duty Occupation. Jobs classified as Heavy Work means that they require frequent lifting up to 100  pounds and frequent carrying of objects weighing up to 50 pounds. A 22-year employee of Estes, our client was a dedicated and very hard worker. Unfortunately for him, his devotion to his job likely had an impact on his body.

Over the course of the years, our client began suffering from a variety of conditions including hypertension, headaches, and ulcers, but his true issues were his Low Back Pain with Sciatica (and thus radiating pain down the leg) and Degenerative Disc Disease. Despite being in constant pain, our client remained at work far longer than he should have. Ultimately, his pain and his back forced him to stop working and he finally did so in August of 2020.

Thankfully, his employer provided its workers with Short Term Disability (STD) and Long Term Disability Insurance Coverage under STD and LTD policies insured by the Life Insurance Company of North America, which has subsequently been purchase by New York Life Insurance Company.

The Inexperienced Law Firm That Left Our Client Out to Dry

The adage that you get what you pay for is almost always true. Following his last day of work, our client sought the help of a social security disability law firm that attempts to help people for free with long term disability claim applications and appeals. This particular law firm has a reputation of doing terrible work on applications and appeals so that a claimant gets denied and then the law firm can try to settle a case for pennies on the dollar. With the help of this free law firm, our client filed his claim for STD benefits, which was quickly approved but ultimately only paid for a one-month period before a denial was issued on that claim. The free law firm then assisted our now client with an appeal to challenge the STD denial and with his application for LTD benefits. Our client was confident that the brief medical records submitted by that firm would quickly prove to the insurance company that there was no way he could do his own heavy duty occupation, but unfortunately for our client, he was wrong and his STD appeal was denied as was the LTD application. Dissatisfied with the free law firm’s quality of work, the client contacted Dell Disability Lawyers and we went to work for him immediately.

The LTD claim was denied via an April 29, 2021 denial letter. In this denial letter, the insurance company informed the Fleet Mechanic that following reviews by an Employee Nurse and an Employee Doctor that it did not find any support for the contention that he could not do his heavy duty job which again required frequent lifting up to 100 pounds and carrying of objects weighing up to 50 pounds, in addition to being able to bend, crawl and contort his body, as one might expect necessary of a guy working as a diesel mechanic. Remarkably, the insurance company’s nurse and doctor found that he was “not functionally limited and no medically necessary activity restrictions and limitations are appropriate.”

This was a shock to this diesel mechanic as every day his life was filled with pain and his own treating providers had repeatedly stated that he couldn’t stand for prolonged periods, lift/transfer 70 pounds, or squat, reach, or climb, etc. Dejected, our now client did nothing on this claim for over 7 months until he finally found our firm online and submitted an online consultation request. Following his reaching out to our firm, he spoke with Attorney Alexander Palamara less than an hour later who quickly requested a copy of the LTD denial letter.

Working with Dell Disability Lawyers

Our now client immediately sent the denial letter to Attorney Palamara who almost found the document to be comical. What our now client was stating and what the insurance company had written seemed as if they were talking about a different individual. But the insurance company’s employee doctor and nurse were truly writing of our now client, however their warped interpretation of the files proved remarkably easy to spot.

Following his signing up with our firm, Attorney Palamara quickly got to work to ensure that our client’s appeal would be as strong as possible. We quickly ordered the claim file from the insurance company as well as updated medical records from all the treating providers. We then arranged a Functional Capacity Evaluation for our client so that an independent physical therapist could run our client through some physical functional testing and then give an opinion on what occupational level he would be able to perform at. And lastly, we began to speak with each of the treating providers to gather additional support from the doctors, therapists and nurses who actually have meet with, spoken with, evaluated, tested and treated our client.

The Filing of the Administrative Appeal

Ultimately for Attorney Palamara who has written over 900 administrative appeals, this appeal proved easy to write as he was armed with so much supportive medical data that there could be no way that the insurance company could deny this claim. With this appeal, he summarized the historical support of each of the treating providers, he pointed to the updated support of the treating providers, and then he listed each piece of objective evidence that showed that his client was certainly disabled. Attorney Palamara then took on the insurance company’s two file reviews which were conducted by a Nurse Case Manager and an unnamed Medical Director who was somehow board certified in Internal Medicine with a specialty in Occupational and Environmental Medicine. Attorney Palamara poked holes in these reports and filled those holes with objective medical data and support from the treating providers.

Lastly, this appeal pointed to the results of the Functional Capacity Evaluation which we arranged for our client where the Doctor of Physical Therapy stated that following the multi-hour examination she believe our client could at most do Sedentary Work.

With this appeal, we left CIGNA/New York Life with no choice but to overturn its denial as the records we compiled and commissioned proved there was just no way that our client could perform the requirements of his Heavy Occupation as a Fleet Diesel Mechanic.  

About 70 days after we filed the appeal, New York Life finally informed us that it was now agreeing that our client was and is disabled and that it had made a determination that the prior decision to deny LTD benefits should be overturned. Additionally, via a separate letter of the same date, New York Life then confirmed that it was reopening and paying all STD benefits owed.

Our client receives benefits to this day. In fact, we continue to work to prove to New York Life that he remains disabled so that he can continue to receive the benefits that he is owed. Our job never stops as we continue to make it difficult for them to ever deny this claim especially in light of the fact that the documentation we utilized for this appeal later convinced the Social Security Administration that he was and is disabled. Thus, now an independent 3^rd party entity also has concluded that he is disabled. Based upon his training, education and experience, we just don’t see how New York Life will ever be able to deny this claim of which are client is eligible for benefits until 2045. However, we will make sure that they never do.

If New York Life or any disability insurance company has denied your claim, please reach out to us immediately as we always offer a free consultation and love challenging these denials.