NY Life Disability Benefits Reinstated on Appeal Despite Independent Medical Examination

Our client, a former high level medical sales representative, suffered from chronic pain stemming from his neck, back and hip that would eventually result in multiple surgeries to include lumbar fusion, cervical fusion and sacroiliac joint fusion. He initially filed his claim for disability benefits at age 62 due to the increasing pain he was experiencing, which made it exceedingly difficult to continue his work as an outside medical device salesman covering a multi-state area. In December of 2018, he filed his claim for short term disability benefits with Cigna, which were approved and then successfully transitioned into long term disability in June 2019. Shortly thereafter, in February of 2020, he was advised his claim for disability benefits had also been approved by the Social Security Administration.

Like the majority of employer provided disability policies, his employer’s long term disability policy contained a 24 month “regular occupation” definition of disability, which means that for the first 24 months of long term disability he would be deemed disabled if he was unable to perform the material duties of his pre-disability occupation, which Cigna had determined to be a “light” duty occupation in the national economy. After the initial 24 months of long term disability the definition of disability changes to mean the inability to perform the material duties of any occupation based on his training, education and experience.

Any Occupation Definition of Disability  Review

While on claim, Cigna was purchased by NY Life and became responsible for the handling and payment of his claim. Six months prior to the transition from the “regular” to “any” occupation change in definition of disability NY Life advised our client that it was beginning its review as to his continued entitlement to benefits. In doing so, NY Life had his file reviewed by an internal nurse case manager, an in-house medical director, as well as sent him for an Independent Medical Examination (IME). The IME doctor determined that despite the fact our client was age 64, had three major surgeries, positive findings on examination and diagnostic medical evidence such as MRIs, that he would be capable of performing at a Sedentary demand level on a full time basis. NY Life took the IME doctor’s opinion, in conjunction with the opinions of its in-house medical personnel and had a vocational analysis performed, which identified two “sedentary” occupations that it felt our client could do. Based on the preceding, two months prior to the actual change in definition, NY Life advised him that his claim was being terminated at the 24 month change in definition as NY Life had determined he was no longer disabled under the terms of the policy.

Appeal of NY LIFE LTD Denial

Following the denial of his claim, our client contacted our office seeking representation for purposes of filing his appeal. Review of the claim file provided by NY Life, with specific attention to the IME report, indicated that NY Life’s reliance on the report was not well founded, as the opinions provided by the IME doctor actually indicated that our client would not be capable of the full gamut of Sedentary work duties. Furthermore, the IME report was silent as to any actual functional physical testing performed. As such, we arranged for our client to undergo a Functional Capacity Examination (FCE) to properly document our client’s physical restrictions and limitations considering Department of Labor standards. The testing documented that our client had multiple restrictions and limitations of across a gamut of testing parameters that resulted in him having No Safe Capacity for Work. Upon receipt of the FCE findings we reached out to two of our client’s doctors to complete customized attending physician’s statements that were drafted based on their prior opinions, the findings of the FCE, as well as to further address the comments of NY Life’s reviewing doctors.

After the filing of the appeal, and prior to the expiration of the 45-day review period, NY Life notified our office that it would be exercising its right to a 45-day extension as it was still performing medical and vocational reviews. During the extension period NY Life provided “form” letter that contained updates regarding the review of the claim. One such letter close to the expiration of the extension period advised our office a decision should be rendered within 30 days. Following the expiration of the 45-day extension and without any response from NY Life as to our requests for an update on the appeal, we filed a federal lawsuit under ERISA based on the denial of benefits and NY Life’s failure to provide a timely review of the claim. In doing so we ensured that important legal rights for our client would be preserved and act as potential leverage against NY Life during the review process.

Within three weeks of filing the lawsuit we received word form NY Life that it was overturning the denial of benefits and reinstating our clients claim for benefits. We continue to represent our client to ensure that the remainder of his benefit will be protected. Although our client only has a short amount of time left on claim given his age the denial of his benefit at age 64 is evidence that NY Life will not hesitate in denying a claim for benefits if it believes it has reasonable grounds to.


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New York Life Reviews
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Showing 8 of 642 Reviews
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Keeps claiming they will not approve claim for pre existing conditions but my illness is not preexisting

Reviewed by M.T. on February 15th 2024   Verified Policyholder | May 2023 date of disability
I have been appealing a claim for LTD for 8 months! New York Life keeps claiming they will not approve claim for pre existing conditions but my illness is not preexisting ... read more >
New York Life

Payment delays!

Reviewed by Kim W on May 7th 2022   Verified Policyholder | September 2021 date of disability
I have a Long term disability claim with New York Life. Approval process did not take too long and they did start my LTD just a few days after my STD ended. First check wa... read more >
New York Life

NYL denied my claim

Reviewed by Trapped in the cogs on March 7th 2022   Verified Policyholder | May 2021 date of disability
I’ve been an RN for 31 years. I lost 6 family members (3 of those to cancer) in 9 months and suffered a breakdown, I just couldn’t watch people die anymore. Cigna (NYL... read more >
New York Life

Hold up on payments!!!

Reviewed by A Crews on January 20th 2022   Verified Policyholder | July 2021 date of disability
I have had 3 people on my case since July 2021! This last person Amanda S drag her feet on my claims and payments. I literally have to go to my mom for help! When I contac... read more >
New York Life

Paid Family Leave

Reviewed by Paid Leave on January 4th 2022   Verified Policyholder | November 2021 date of disability
I haven’t received a single check while on paid family leave for over a month. Thankfully my wife is receiving from her job while on maternity leave. New York Life is ri... read more >
New York Life

They should all rot in hell

Reviewed by Shawn on January 2nd 2022   Verified Policyholder | September 2020 date of disability
NY Life had been paying on my LTD policy for 7 months when I reached $100,000 in claims they had paid for me. Immediately my policy I had through my employer changed, the ... read more >
New York Life

They will constantly come up with anything to delay paying you

Reviewed by Jackie on November 1st 2021   Verified Policyholder | August 2020 date of disability
I have been on disability since august of 2020 and it is now November 2021. I have not seen a dime from them and every time I call it's always something else they need or ... read more >
New York Life

Don't count on New York Life!!! You will be very disappointed!!!

Reviewed by Evan on October 27th 2021   Verified Policyholder | September 2021 date of disability
I had complications to a previous hip surgery. I was given some time off to get the issues figured out. During this time I had complications with my prostate gland. I ende... read more >
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