We lately gained a big victory for a consumer who was wrongfully denied long-term incapacity (LTD) advantages by New York Life (NYL).
Our consumer, a former registered nurse, has been battling quite a few debilitating medical situations, together with pudendal neuralgia, advanced regional ache syndrome, Ehlers-Danlos syndrome, PTSD, nervousness, 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 overview 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 based mostly 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 consumer to be unable to carry out any occupation that paid at the least 60% of her pre-disability revenue.
- Biased IME and Peer Evaluate: NYL ordered an Unbiased Medical Examination (IME), which acknowledged ache on bodily examination, however set gentle limitations and, shockingly, recommended malingering and identified our consumer with Munchausen’s Syndrome.
- Flawed Transferable Abilities Evaluation: NYL carried out a transferable expertise evaluation with no wage threshold and, unsurprisingly, concluded that she may work. This strategy blatantly ignored the necessities of the coverage.
- ERISA Violations: Maybe most egregiously, NYL failed to supply the IME, peer overview, and transferable expertise evaluation studies to our consumer or her lawyer earlier than terminating her advantages. This disadvantaged the claimant a full and honest overview 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 staff on the Ortiz Legislation Agency instantly sprang into motion, submitting a complete enchantment 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 data and statements from her treating physicians, highlighting her ongoing care and the severity of her situations.
- Exposing Flawed Evaluations: We methodically deconstructed the IME and peer overview, 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 supply our consumer with a full and honest overview.
The Outcome: A Swift Victory
Confronted with overwhelming proof, NYL reinstated our consumer’s advantages in lower than 30 days. This determination gave her the monetary safety she desperately wanted to give attention to 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 battle tirelessly to get our shoppers the advantages they deserve. Name us immediately at (888) 321-8131 or fill out our on-line contact kind for a free case analysis. Allow us to aid you safe your advantages and maintain the insurance coverage firms accountable.
