We lately received a major victory for a shopper who was wrongfully denied long-term incapacity (LTD) advantages by New York Life (NYL).
Our shopper, a former registered nurse, has been battling quite a few debilitating medical circumstances, together with pudendal neuralgia, advanced regional ache syndrome, Ehlers-Danlos syndrome, PTSD, anxiousness, main depressive dysfunction, and migraines, which have left her unable to keep up gainful employment.
After efficiently interesting her declare in 2023, NYL started a brand new assessment course of when the two-year definition of incapacity modified from “personal occupation” to “any occupation.” Throughout this course of, NYL wrongfully terminated her advantages primarily based on deeply flawed and inappropriate evaluations.
The Denial: New York Life’s Missteps
We asserted that NYL’s denial of advantages had quite a few authorized errors, together with the next:
- Incorrect Definition of “Any Occupation”: The claims adjuster misinterpreted the coverage, making use of a definition of “any occupation” with out an earnings threshold. This interpretation ignored the plain language of the coverage, which required that the shopper to be unable to carry out any occupation that paid at the very least 60% of her pre-disability revenue.
- Biased IME and Peer Assessment: NYL ordered an Impartial Medical Examination (IME), which acknowledged ache on bodily examination, however set gentle limitations and, shockingly, instructed malingering and recognized our shopper with Munchausen’s Syndrome.
- Flawed Transferable Abilities Evaluation: NYL performed a transferable abilities evaluation and not using a wage threshold and, unsurprisingly, concluded that she may work. This method blatantly ignored the necessities of the coverage.
- ERISA Violations: Maybe most egregiously, NYL failed to offer the IME, peer assessment, and transferable abilities evaluation studies to our shopper or her legal professional earlier than terminating her advantages. This disadvantaged the claimant a full and honest assessment in that it didn’t give her a chance to reply to these flawed assessments earlier than a termination in advantages.
How We Fought Again
Our group on the Ortiz Legislation Agency instantly sprang into motion, submitting a complete attraction that dismantled NYL’s rationale for the denial. Right here’s how we turned the case round:
- Proof of Ongoing Medical Care: We submitted up to date medical information and statements from her treating physicians, highlighting her ongoing care and the severity of her circumstances.
- Exposing Flawed Evaluations: We methodically deconstructed the IME and peer assessment, demonstrating their inaccuracies, bias, and lack of adherence to medical requirements.
- Coverage Language: We highlighted the clear coverage definition of “any occupation,” which required a 60% earnings threshold, proving that NYL had misapplied its personal phrases.
- ERISA Violations: We outlined NYL’s failure to offer our shopper with a full and honest assessment.
The Consequence: A Swift Victory
Confronted with overwhelming proof, NYL reinstated our shopper’s advantages in lower than 30 days. This choice gave her the monetary safety she desperately wanted to concentrate on her well being and well-being.
Want Assist with a Denied Lengthy-Time period Incapacity Declare?
In case your long-term incapacity advantages have been unfairly denied, the Ortiz Legislation Agency is right here to assist. We struggle tirelessly to get our purchasers the advantages they deserve. Name us right this moment at (888) 321-8131 or fill out our on-line contact type for a free case analysis. Allow us to make it easier to safe your advantages and maintain the insurance coverage firms accountable.
