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Posted on Tuesday, January 25th, 2022 at 2:58 pm    

Proving Physical Disability form any Gainful Occupation due to Chronic Pain from Low Back Pain, Neck Pain, and Fibromyalgia*

A female client in her 50’s had her long term disability benefits terminated by New York Life insurance company (doing business as Cigna) as of the date her long term disability insurance policy transitioned its definition of “Disability” from the individual’s ability to perform her regular occupation to any gainful occupation. After paying 24 months of LTD benefits, the insurance carrier applied the LTD policy’s mental health limitation and alleged that our client was no longer physically disabled from performing full-time sedentary employment. However, our client had a long history of multiple, co-morbid physical impairments causing chronic pain that most significantly impacted her lower back, neck, joints, and muscles. Additionally, our client’s prior work history was in information technology, and the policy required that New York Life:

  1. Identify occupations for which she would qualify based on her education, training, and experience.
  2. Satisfy a significant wage requirement for the other occupation to be considered gainful.

Prior to terminating benefits, the insurance company requested an independent medical examination with an occupational medicine physician. This physician alleged that our client was physically capable of performing most sedentary and light work activities. After the termination of benefits, our client submitted her first appeal on her own. That appeal was unsuccessful. Capitan Law was retained to develop and submit a voluntary appeal. The appeal development involved medical record retrieval where the insurance company was not in possession of a great deal of records, obtaining medical opinions from treating physicians specific to the any gainful occupation standard of Disability, and raising a multitude of arguments in support of our client’s physical disability from any gainful occupation beyond the 24-month mark of benefits payable.

For this particular case, most of the administrative appeal work was performed during the appeal process. The long term disability appeal process was complicated by many “review and respond” exchanges. In sum, the insurance company would proffer the reports of multiple non-examining physicians alleging that our client was capable of full-time employment, to which we responded on our client’s behalf in a meaningful and purposeful fashion in further support of our client’s long term disability appeal. After 8 months of an intensive, back-and-forth appeal review process, our client’s benefits were reinstated as of the date of termination with monthly benefits continuing into the future.

Our law firm highly recommends that any disabled claimant facing a denial of termination of benefits retains an experienced disability insurance lawyer for representation during the administrative appeal process and, ideally, well before that person is involved in the “review and respond” phase of the long term disability appeal review process. Our law firm’s legal consultations are free.

*DISCLAIMER: The results in this one particular long term disability case do not reflect results in all disputed insurance claims. We do not make any guarantees as to the outcome of any one case or issue. The above case study is for informative and educational purposes only.

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