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When New York Life terminated our client’s long-term disability (LTD) benefits at the “any occupation” stage, the decision was based on paper reviews that ignored the full picture of her medical condition. We filed a comprehensive ERISA appeal — and New York Life reversed course entirely, reinstating her benefits without a single day in court.
What Does an “Any Occupation” Denial Mean for Your LTD Claim?
Most long-term disability policies begin with an “own occupation” definition: you’re considered disabled if you can’t perform your specific job. After a defined period — typically 24 months — the policy shifts to a stricter “any occupation” standard, meaning the insurer only continues benefits if you can’t work in any job for which you’re reasonably qualified by education, training, or experience.
This transition is one of the most common trigger points for LTD terminations. Insurers like New York Life use the standard change as an opportunity to scrutinize claims with fresh eyes — and sometimes with a bias toward termination rather than a genuine evaluation of the claimant’s limitations.
In our client’s case, New York Life paid her benefits throughout the full 24-month own occupation period. Then, as the policy transitioned to the any occupation standard, the insurer initiated a review. What followed was a denial process that cut corners, disregarded treating physician opinions, and withheld key evidence from the claimant before issuing its termination decision.
Was your LTD claim terminated at the “any occupation” stage? Call the Ortiz Law Firm at (888) 321-8131 for a free consultation.
What Medical Conditions Did This Claimant Have?
Our client’s disability was not the result of a single straightforward condition. She became unable to work following a motor vehicle accident that triggered a complex, multi-system medical picture — one that would have been difficult to fully grasp without carefully reviewing the record as a whole.
Her conditions included an autoimmune disorder, connective tissue disorder, neurological impairment, chronic pain syndrome, and significant cognitive and psychiatric conditions. Individually, any one of these diagnoses would present real functional limitations. Together, they created a compounding effect that multiple treating providers confirmed left her unable to engage in sustained work activity of any kind.
This is precisely the kind of claim that requires a thorough, integrated review of the full medical record — not a selective reading of individual diagnoses in isolation.
How Did New York Life Justify Terminating Her Benefits?
Did New York Life Rely on Doctors Who Actually Examined Her?
No. Rather than arranging an independent medical examination with a physician who would actually see our client in person, New York Life commissioned paper file reviews — evaluations conducted by non-examining physicians and a psychologist who reviewed only the documents in the claim file.
These reviewers minimized or outright ignored the totality of her conditions, discounted the opinions of her treating providers, and assigned functional capacities that were inconsistent with the medical record. Paper reviews are a standard insurer tool, but their reliability depends heavily on whether the reviewer genuinely engages with all of the evidence — and here, that did not happen.
RELATED POST: New York Life’s Independent Medical Review Process and How to Respond
Did the Transferable Skills Analysis Account for Her Real Limitations?
No. New York Life commissioned a transferable skills analysis to identify occupations the claimant could allegedly perform. That analysis was built on the flawed functional capacity assumptions generated by the paper reviewers — assumptions that failed to account for her well-documented physical limitations, cognitive impairments, and the side effects of her medications.
The result was a list of hypothetical sedentary occupations that looked reasonable on paper but had no meaningful connection to what this claimant could actually do in a real workplace on a sustained basis.
Did New York Life Follow ERISA’s Fair Review Requirements?
This is where New York Life’s process had a significant procedural problem. Under ERISA, claimants are entitled to a full and fair review of their claims. A critical component of that right is the opportunity to see and respond to adverse evidence before a final decision is issued.
New York Life did not provide our client with copies of the adverse medical reviews or the transferable skills analysis before terminating her benefits. She had no meaningful opportunity to review that evidence, submit a rebuttal, or correct errors in the record during the administrative process. This failure to disclose adverse evidence is not just a procedural misstep — it’s a violation of ERISA’s full-and-fair-review requirements.
If New York Life denied or terminated your disability claim, you have the right to appeal. Ortiz Law Firm handles ERISA disability appeals nationwide. Call (888) 321-8131 today.
What Did the ERISA Appeal Include?
An effective ERISA appeal is not simply a letter of disagreement. It is a comprehensive legal and medical submission that rebuilds the record and directly addresses every flaw in the insurer’s reasoning. Our appeal to New York Life did exactly that.
The appeal package included extensive updated medical records, sworn statements from the claimant, opinions from her treating providers addressing her functional limitations, and detailed documentation of the side effects of her medications — an element that insurers frequently overlook but that significantly limits a claimant’s ability to work.
We also submitted a fully favorable Social Security Disability Insurance (SSDI) award. While insurers are not bound by Social Security’s findings, a favorable SSDI determination is powerful evidence that an independent federal agency reviewed the same record and found the claimant disabled from all work. New York Life’s failure to even acknowledge that determination was itself evidence of cherry-picking.
The appeal demonstrated that New York Life had selectively relied on evidence that supported termination while disregarding evidence that supported continued disability — and that the procedural failure to disclose adverse evidence before the denial had compromised the integrity of the entire review process.
What Was the Outcome of the Appeal?
Following its review of our comprehensive appeal, New York Life overturned its termination decision and reinstated our client’s long-term disability benefits in full. Her financial security was restored without the need for litigation.
When we calculate the full value of what was recovered — including back pay and ongoing monthly benefits through the end of the policy — the total recovery for this client comes to over $270,000.
That number represents more than a legal victory. It represents years of financial stability for a claimant whose insurer had already decided she didn’t qualify. An ERISA appeal, when built correctly, can produce this kind of result — even from insurers who have already said no.
Don’t face New York Life alone. The Ortiz Law Firm has the experience to build the appeal that gives you the best chance at reinstatement. Call (888) 321-8131 or for a free case review.
