Winpak Process Manager With Degenerative Spine Disease Wins Florida New York Life LTD Insurance Appeal After Denial at 24 Months
New York Life denied continued long-term disability benefits to our client — a Florida process manager employed by Winpak with L5-S1 spondylolisthesis and related spinal conditions — at the exact moment his policy’s definition of disability changed from own-occupation to any-occupation. The insurer relied entirely on a paper review by a non-examining physician who never saw our client, never spoke to him, and never examined him — yet concluded he could return to sedentary work despite the reviewer’s own acknowledgment that our client had pain with both sitting and walking.
We have handled thousands of New York Life disability insurance claims, and this case followed a pattern we see over and over again: an insurer pays benefits for two years, then uses the 24-month definition change as a convenient exit ramp — supported by a desk review that cherry-picks favorable findings while ignoring the treating physicians, the objective imaging, and the claimant’s actual functional capacity. Attorney Stephen Jessup assembled a comprehensive appeal that exposed every flaw in that approach, and New York Life reversed its decision.
Below, we break down how the denial was built, how we dismantled it, and what every claimant approaching a definition change should understand about protecting their benefits. If New York Life or any other disability insurance company has denied your claim, speak with one of our long-term disability insurance lawyers for a free consultation. We represent claimants nationwide and charge no fee unless your benefits are paid.
Table of contents
- Why this case matters for every New York Life claimant
- A manufacturing supervisor disabled by spinal disease after multiple failed surgeries
- New York Life’s denial — a paper review that contradicted its own findings
- Building the appeal — the evidence New York Life never sought
- The FCE: below sedentary with validated effort
- Treating physicians confirm total disability
- New York Life reverses its decision in full
- Protect your disability benefits — talk to our attorneys today
Why This Case Matters for Every New York Life Claimant
The 24-month definition change is a deliberate chokepoint — prepare for it before it arrives. Most long-term disability policies shift the standard of disability after 24 months of benefit payments. Under the own-occupation standard, the insurer only needs to show you can do your specific job. Under the any-occupation standard, the insurer can terminate benefits if it believes you can perform any job matching your education, training, or experience. A 24-month own-to-any occupation definition change is the contractual point at which a disability insurance policy shifts from measuring whether you can perform your own job to measuring whether you can perform any job for which you are qualified. This transition is one of the most common triggers for benefit termination — and one every claimant should anticipate.
A paper review is not a substitute for an in-person examination. New York Life’s reviewing physician — Dr. Anthony Watson, a board-certified orthopedic surgeon — never examined our client. He relied entirely on medical records, yet felt confident concluding that a man with three back surgeries, two cervical fusions, and documented pain in every postural position could return to work at a sedentary desk job. A file review, also called a paper review, is a medical opinion based solely on a claimant’s existing records without any in-person examination. When an insurer relies on a paper review to deny benefits, the claimant should treat it as a red flag — and an opportunity to build a stronger record on appeal.
When the insurer’s own reviewer contradicts himself, the denial is built on a cracked foundation. Dr. Watson acknowledged in his review that our client had pain with sitting and walking. He then imposed no sitting restrictions whatsoever and cleared him for sedentary work — which by definition requires constant sitting. That internal contradiction was not an oversight. It was a conclusion looking for supporting data and ignoring whatever did not fit.
An independent Functional Capacity Evaluation can be the single most powerful piece of evidence on appeal. A Functional Capacity Evaluation, or FCE, is a standardized, in-person battery of physical tests administered by a licensed evaluator that measures what a person can actually do — how long they can sit, stand, walk, lift, carry, and sustain physical effort. Our client’s FCE produced a validated, good-effort result of Below Sedentary — meaning he could not sustain even a desk job. That result eliminated every occupation New York Life had identified.
Treating physician opinions backed by objective testing create an evidentiary chain that paper reviewers cannot break. Both of our client’s treating physicians — his spine surgeon and his pain management specialist — independently documented specific sitting, standing, and walking limitations that precluded all gainful employment. When the pain management physician then reviewed and agreed with the FCE findings, the appeal presented a unified body of evidence that no desk review could credibly dispute.
A Manufacturing Supervisor Disabled by Spinal Disease After Multiple Failed Surgeries
Our client worked as a WAU Process Manager for Winpak, Inc., a manufacturing company. His role was classified as a Medium Level Occupation under the Department of Labor’s Dictionary of Occupational Titles, meaning it required exerting 20 to 50 pounds of force occasionally and 10 to 25 pounds frequently. He was responsible for coordinating and assisting production and maintenance departments, overseeing training and development of supervisors and lead operators, approving and conducting R&D trials, and maintaining dialogue with vendors and support groups across the organization.
He stopped working due to L5-S1 spondylolisthesis (ICD-10: M43.16) — a condition in which one vertebra slips forward over the one below it — along with bilateral L5 lumbar radiculopathy (M54.17), cervical radiculopathy (M54.12), and chronic pain syndrome (G89.4). His treatment history tells the story of a body that has not responded to anything medicine has tried.
Five Surgeries and No Resolution
Our client underwent three back surgeries: an initial instrumented fusion at L5-S1 with cages and rods, a revision surgery to remove a screw that had migrated into his sciatic nerve, and an anterior lumbar fusion to remove all hardware. He also had two prior cervical anterior discectomy and fusion surgeries. In addition to surgery, he tried chiropractic therapy, physical therapy (which worsened his pain), epidural steroid injections, a TENS unit, and pain medication. None of these measures resolved his symptoms. At the time of the denial, a revision laminectomy at L5-S1 was being considered if a spinal cord stimulator proved ineffective.
Post-Surgical Imaging Confirmed Ongoing Structural Disease
Post-surgical MRI imaging of both the lumbar and thoracic spine revealed extensive ongoing pathology. Research confirms that lumbar degenerative spondylolisthesis is a significant contributor to functional disability, and our client’s imaging demonstrated exactly why. The lumbar MRI showed degenerative changes at multiple levels:
- L1-2 and L2-3: Facet and ligamentum flavum hypertrophy — thickening of the joint structures and spinal ligaments that narrows the space available for nerves.
- L3-4: Facet arthropathy and congenital pedicular hypoplasia — naturally undersized vertebral bone structures that further reduce the space available for nerves.
- L4-5: Disc bulge, facet arthropathy, and congenital pedicular hypoplasia resulting in left neural foraminal stenosis.
- L5-S1: Disc bulge and annular fissure superimposed on the spondylolisthesis, resulting in moderate bilateral neural foraminal stenosis — narrowing of the openings through which spinal nerves exit the vertebral column, compressing nerves and causing radiating pain, numbness, or weakness in the legs.
The MRI also confirmed a fixed grade 1 anterolisthesis of L5 on S1 — the vertebral slippage that defined his primary diagnosis — along with remote discectomy and fusion changes with associated anterior and posterior fusion hardware.
A thoracic spine MRI documented chronic multilevel spondylosis and degenerative disc disease (ICD-10: M47.814) with mild to moderate spinal canal stenosis at T7-T8, spinal canal stenosis at T10-T11, and bilateral foraminal stenosis at multiple levels. This was not a case where imaging was silent. The structural damage was visible, documented, and extensive.
New York Life’s Denial — A Paper Review That Contradicted Its Own Findings
New York Life’s denial arrived precisely at the 24-month mark — the point at which the policy’s definition of disability shifted from own-occupation to any-occupation. Under the Employee Retirement Income Security Act (ERISA), which governs employer-sponsored group disability plans, the insurer is required to provide a full and fair review of the claim. What our client received was anything but.
The Insurer’s Medical Director Acknowledged Pain — Then Ignored It
New York Life’s Medical Director, Dr. Anthony Watson — a board-certified orthopedic surgeon who never examined our client — reviewed the medical records and arrived at a conclusion that contradicted his own findings. Dr. Watson acknowledged that our client had “pain with both sitting and walking” and “low back pain radiating to the buttocks that was worse with sitting and lying down.” He noted that our client “could sit for 30 minutes before having to change positions.”
Despite all of this, Dr. Watson imposed no sitting restrictions. None. He cleared our client for sedentary work — a classification that the Department of Labor defines as involving sitting most of the time. The logic was circular: acknowledge the pain, then pretend it does not affect the ability to sit all day. That is an assumption, not a medical conclusion. We have seen New York Life use this same approach in other cases — including one where the insurer denied benefits to a project manager with migraines based on a similarly flawed paper review, a denial we also reversed.
Dr. Watson Dismissed Treating Physician Findings Without Adequate Basis
Dr. Watson also took issue with the clinical findings of our client’s pain management physician. He claimed that the pain management specialist’s findings of bilateral knee weakness were “not substantiated” by the lumbar MRI — and argued it was “biologically impossible” for stenosis severe enough to affect motor innervation to have developed in the six months between the MRI and the pain management evaluation. In plain terms, the nerves that control knee strength originate from the L2 through L4 spinal levels, and Dr. Watson asserted the MRI did not show enough compression at those levels to explain the weakness. This was a paper reviewer substituting his own theoretical timeline for the clinical observations of a treating physician who had actually examined the patient. Dr. Watson also pointed to an earlier physical examination showing “normal gait” and “normal bilateral lower extremity strength” — but that single snapshot was months before the denial and did not account for the documented deterioration in our client’s condition.
The TSA Identified Sedentary Occupations the Claimant Could Not Perform
Based on Dr. Watson’s restrictions — which included no sitting restrictions and only occasional limitations on standing and walking — New York Life’s Vocational Rehabilitation Specialist conducted a Transferable Skills Analysis. A Transferable Skills Analysis, or TSA, is an assessment that matches a claimant’s education, training, and work experience against the physical demands of alternative occupations to determine whether any jobs exist that the claimant could theoretically perform. The TSA identified two sedentary occupations: Production Scheduler (DOT Code 012.167-050) and Quality Control Supervisor (DOT Code 559.134-010). New York Life concluded our client could perform these roles and terminated his benefits.
The entire edifice — the sedentary occupations, the TSA, the termination — rested on Dr. Watson’s no-sitting-restriction conclusion. Remove that, and everything collapsed.
Building the Appeal — The Evidence New York Life Never Sought
Attorney Stephen Jessup filed a comprehensive New York Life long-term disability insurance appeal that attacked the denial on every front. The appeal did not simply disagree with the outcome — it demonstrated that the denial was built entirely on the flawed foundation of a paper review that contradicted its own findings, ignored treating physician opinions, and was unsupported by any in-person evaluation.
The appeal highlighted three central failures in New York Life’s review:
- The internal contradiction: Dr. Watson acknowledged sitting pain yet imposed no sitting restrictions — then cleared our client for a classification of work that requires constant sitting.
- The failure to examine: New York Life never arranged an independent medical examination. The insurer made a life-altering benefits decision based entirely on a desk review of existing records.
- The dismissal of treating physicians: Both of our client’s treating physicians — his spine surgeon and his pain management specialist — had consistently documented that our client could not perform any gainful employment. New York Life set aside those opinions in favor of a reviewer who had never been in the same room as the patient.
But the appeal did more than point out what was wrong with the denial. It submitted the evidence New York Life never gathered.
The FCE: Below Sedentary With Validated Effort
Because New York Life never examined our client in person, we arranged an independent Functional Capacity Evaluation. This is not the first time we have had to fill the evidentiary gap that an insurer left open — in another case, we secured reinstatement of New York Life disability benefits even after the insurer conducted its own independent medical examination. Here, the insurer did not bother with an examination at all. The FCE was conducted by two qualified evaluators — a Disability Examiner and Vocational Evaluator with a Master’s degree, and a licensed Physical Therapist and Functional Capacity Evaluator. After hours of standardized testing, the results were unambiguous.
A Valid Test With Good Effort — and a Below Sedentary Result
The evaluators assigned a validity score of 82%, indicating a valid test with good effort. Validity is determined through isometric and dynamic tests, hand tests, and consistency of movement patterns. Critically, our client did not demonstrate Symptom Magnification behavior — meaning he was not exaggerating his limitations. His pain was real, his effort was genuine, and his functional capacity was measured objectively. The result: Below Sedentary. The Department of Labor defines sedentary work as exerting up to 10 pounds of force occasionally and involving sitting most of the time. A Below Sedentary result, also called Less Than Sedentary, means a person cannot sustain even the minimal physical demands of a desk job.
The Specific Functional Limitations That Eliminated Every Identified Occupation
The FCE documented precise limitations across every relevant physical demand:
- Lifting: Could lift waist-to-shoulder and carry up to 10 pounds occasionally, but could only lift waist-to-overhead, push, and pull up to 8 pounds occasionally. Unable to safely lift any weight from the floor.
- Postural tolerances: Could only sit, stand, and walk occasionally — meaning for no more than one-third of the workday. Could only infrequently bend, stoop, squat, and climb stairs.
- Safety limitations: Unable to safely kneel, crawl, balance, or reach overhead with either hand.
- Cardiovascular status: Overall cardiovascular level was rated poor. Heart rate and blood pressure were in the high normal ranges with normal changes during evaluation.
- Lower extremity weakness: Noted weakness in the left leg, preventing safe floor-level lifting.
The evaluators concluded: our client “did not demonstrate the ability to perform the full exertional demands of the SEDENTARY Classification level.” He could not sit, stand, or walk for more than occasional periods. The two sedentary occupations New York Life had identified — Production Scheduler and Quality Control Supervisor — both required sustained sitting. Our client could not do it.
Treating Physicians Confirm Total Disability
The appeal included updated physician statements from both of our client’s treating providers. Their opinions were consistent, specific, and unequivocal — and they directly contradicted the conclusions of New York Life’s non-examining reviewer.
The Spine Surgeon: Not Able to Return to Work
Our client’s spine surgeon completed an Attending Physician Statement noting pain in the lower back radiating down both legs. He documented that our client had trouble performing basic activities of daily living — difficulty putting on shoes, increased pain when lying down, and functional impairment throughout his daily routine. His assessment was direct: our client was not able to return to work and could not return even with accommodations. He noted our client was awaiting evaluation for a spinal cord stimulator trial and that a return-to-work date could not be determined. During an office visit, the spine surgeon observed that our client “seems to continue to be debilitated in terms of his sitting and walking tolerance” and “could not perform any work.”
The Pain Management Specialist: Not Capable of Gainful Employment
Our client’s pain management specialist provided specific functional restrictions: no lifting over 10 pounds, no sitting or standing for more than 20 minutes, and no bending or twisting. When New York Life’s Nurse Case Manager asked the pain management physician directly whether our client was capable of performing sedentary work, his response left no room for interpretation: “I disagree. He has severe limitations with sit, stand, walking activity. Not capable of gainful employment.”
After the FCE was completed, the pain management specialist reviewed the results and agreed with the findings. In a subsequent Attending Physician Statement, he confirmed objective signs including MRI abnormality, decreased range of motion, weakness, positive straight leg raise testing — a clinical sign indicating nerve root irritation in the lower spine — slow and guarded movement patterns, reduced strength, and guarded posture. He opined that our client would frequently require unscheduled interruptions of work, would frequently miss work due to symptom exacerbations, would frequently be off task, and would be an unreliable employee. His final conclusion: our client was unable to perform the duties of any gainful occupation.
This is the difference between a paper review and actual clinical care. Dr. Watson reviewed records from a desk. Our client’s treating physicians examined him, treated him, watched him struggle to sit in a chair, and documented what they observed. When those physicians then confirmed the findings of an independent, validated FCE, the evidentiary picture was complete.
New York Life Reverses Its Decision in Full
After reviewing the appeal — including the FCE results, the updated treating physician statements, the additional MRI imaging, and the comprehensive medical records — New York Life overturned its prior decision. The insurer confirmed that our client’s benefits would continue beyond the any-occupation date, with ongoing eligibility based on periodic medical review.
This did not happen by accident. New York Life reversed course because the appeal left no room for the insurer to maintain its position. Every pillar of the denial had been dismantled:
- The paper reviewer’s no-sitting-restriction conclusion was contradicted by the FCE’s Below Sedentary result and by both treating physicians’ documented sitting limitations.
- The two sedentary occupations identified by the TSA were eliminated — our client could not sustain sitting for more than occasional periods, which is incompatible with any sedentary job.
- The failure to arrange an in-person examination was exposed by the appeal’s inclusion of an independent FCE that New York Life itself should have ordered.
We have seen this same pattern in case after case. In one recent example, New York Life denied benefits to a tech specialist with PTSD based on a paper review that ignored two decades of treating physician observations — and we reversed that denial as well. The insurer uses the 24-month definition change as an opportunity to terminate benefits, relies on a paper review rather than an in-person evaluation, and counts on the claimant not knowing how to fight back. When the claimant does fight back — with the right evidence, the right medical support, and experienced disability insurance attorneys — the denial falls apart.
Protect Your Disability Benefits — Talk to Our Attorneys Today
As attorney Stephen Jessup wrote in the appeal: “Considering [our client’s] complicated medical history, failure of conservative measures and surgical intervention, the corroborative objective evidence in his medical records, the opinions of [his] board certified physicians, and the FCE results, it is clear that [he] cannot perform the material duties of any occupation.”
If New York Life or any other disability insurance company has denied your long-term disability benefits — especially at the 24-month definition change — you do not have to accept it. Many claimants wonder whether they can appeal a New York Life disability denial, and the answer is yes — you have the right to appeal under ERISA, and you do not have to do it alone. An ERISA administrative appeal is a formal challenge to an insurer’s benefit denial, filed under federal law, that must be exhausted before a claimant can pursue a lawsuit against New York Life. There are strict deadlines — in most cases, you have only 180 days from the date of denial to file. Do not wait.
Dell Disability Lawyers has been representing disability insurance claimants with back disorders and every other disabling condition since 1979. We have helped tens of thousands of claimants nationwide recover more than two billion dollars in disability benefits. We handle every case on a contingency basis — you pay no fee unless we recover your benefits.
Contact our office for a free consultation with one of our experienced long-term disability insurance attorneys.
