Teacher Wins New York Life LTD Insurance Appeal for Chronic Pain

Our client, a former school teacher, suffering from multiple severe medical conditions including autonomic nervous system damage, small fiber neuropathy, a history of prior back surgery, and severe immune conditions had been receiving long term disability benefits through New York Life for approximately two years under his school system’s group disability policy when he first contacted our office. Like the vast majority of New York Life disability policies, his plan had a two year own occupation definition of disability, which required New York Life to determine his eligibility for disability benefits based on the inability to perform the material and substantial duties of his pre-disability occupation for the first two years of the claim. After that point the standard of disability would shift to the inability to perform the material and substantial duties of any occupation that he would be qualified to perform based on his training, education and experience. At the time of his initial contact with Attorney Stephen Jessup, New York Life was actively in the process of reviewing his claim for continued benefits under the any occupation standard of disability.

The IME and Any Occupation Review

What was most concerning to Attorney Jessup about New York Life’s any occupation review was the request made for an Independent Medical Examination (IME). Under the terms of the policy our client would be obligated to attend an IME at the request of New York Life and failure to do so could result in grounds for a denial of benefits. Requests for an IME with a doctor qualified to treat/comment on an individual’s specific medical condition are not uncommon. What made this request troublesome was the fact that the doctor selected by New York Life to perform the IME was not the correct medical specialty for our client’s conditions. The IME doctor was an orthopedic doctor, and given our client’s conditions should have been a neurologist or infectious disease specialist. Raising an eyebrows even further was the fact that our client was located only ten miles from the city of Provo, yet New York Life wanted him to attend an IME over 60 miles away in Ogden.

At that time our client decided to wait to hire our office to assist him and to address with New York Life, on his own, the concerns expressed by Attorney Jessup as they related to the IME doctor. New York Life did ultimately agree to change the location of the IME to a closer location. However, instead of having the IME performed by a Neurologist or Infectious Disease Specialist, New York Life ultimately chose to send our client to a doctor who specialized in Physical Pain and Rehabilitation. Our client would later tell Attorney Jessup that the IME doctor told him during the exam that he should have been examined by a Neurologist. Regardless, the IME doctor determined our client would have extensive physical ability in excess of light duty work, and as a result New York Life would ultimately terminate benefits after finding that our client would be able to return to work in his former light duty occupation as a teacher as well as alternate sedentary demand level jobs. What makes this determination even more absurd is the fact that shortly before the IME appointment our client was informed by the Social Security Administration that his claim for Social Security Benefits had been approved.

The Denial and Benefits Reinstated

After receiving the denial letter our client decided he could not handle New York Life on his own hired Attorney Jessup to take over his claim. Immediately, Attorney Jessup sent a letter of representation to New York Life requesting a complete copy of his claim file and informed New York Life that they were to have no additional contact with our client and that all communication was to be sent directly to our office. Attorney Jessup followed up on outstanding medical requests so pertinent records could be supplied to New York Life to refute the clearly erroneous basis of the denial. Realizing the fight that would be forthcoming and recognizing errors in the claims process New York Life notified Attorney Jessup within weeks that it was reinstating our client’s monthly benefit. 

Despite reinstating his long term disability claim New York Life is still challenging the Waiver of Premium claim attached to our client’s Life Insurance policy, which Attorney Jessup is currently appealing.

It is clear that our client should have never been denied benefits. Despite his young age, his complex medical history clearly establishes restrictions and limitations that even the Social Security Administration recognizes would prevent him from returning to meaningful employment.

This case serves as an example as to how New York Life’s review of a disability claim can be marred with clear and evident flaws, and that even when brought to New York Life’s attention, New York Life will still do little to rectify the problem. New York Life will stop at nothing to find any rationale to fit its agenda to deny a claim – even if that rationale is devoid of logic.

If your claim is being challenged, reviewed or denied by New York Life please contact our office to discuss your situation with one of our disability attorneys.