Long-Term Disability Insurance Won for Heavy Equipment Operator

Long Term Disability Insurance Denial by New York Life Insurance Company Reversed on Appeal for Heavy Equipment Operator with Heart Disease

Our client Jim (not his real name), a 58-year-old family man and sole breadwinner, was a Heavy Equipment Operator for his whole career. But after a heart attack, his heart disease and lack of cardio capacity caused shortness of breath, dizziness, and complete numbing of his hands.

New York Life Insurance Company agreed that Jim’s heart disease disabled him from being a Heavy Equipment Operator and paid him disability benefits of 60% of his $78,000 annual salary for 24 months.

But after paying for 24 months, they terminated Jim’s benefits. They claimed that, while he remained disabled from the required duties of a Heavy Equipment Operator, he was capable of performing the duties of other sedentary desk-job occupations.

The insurer based its termination of benefits on an extremely shallow vocational expert’s report that didn’t properly analyze all the duties of these desk jobs, each of which required computer skills that Jim clearly lacked. The insurer’s vocational expert never interviewed or met with Jim.

From the “Own Occupation” to the “Any Occupation” Policy Definition of Disability

In long-term disability policies, the definition of “disability” can vary from policy to policy. This definition drives what the claimant must prove to be considered disabled under the policy.

Most policies have variations of two definitions for disability.

Typically, for the first 24 months, a claimant only has to be unable to perform their “own occupation.” The definition of “own occupation” is found in the policy. Usually, it will state that the definition is based on how the job is performed in the national economy as defined by the Dictionary of Occupational Titles, not how the claimant actually performs his or her own occupation.

In most policies, after 24 months, a claimant must prove that he or she cannot perform “any occupation.” Usually, the definition includes “any occupation” that the claimant can perform based on his or her education, background, and skills.

The “any occupation” standard often also includes a salary percentage component. This provision means that the company cannot deny benefits on the basis that the claimant can perform the duties of any job, at any wage. Instead, to support a denial, the insurance company must identify occupations that will pay the claimant, usually at least 80 percent (typically) of their pre-disability income.

In many cases, the disability insurance company will pay benefits for the first 24 month “own occupation” period, then terminate benefits under the “any occupation” provision. This triggers the start of the administrative appeal process, the same as an initial claim denial.

Justice Delivered on Appeal

A disability insurer can’t just point to jobs someone can physically perform within his or her medical restrictions and label the person not disabled. The job needs to be one that the disabled victim can perform given his or her current skill level without the need of extensive new training.

Jim helped us develop a detailed educational and work-experience background, with special attention to his lack of computer experience. We also got vocational expert input of our own to prove that Jim, although physically capable, simply did not have the skillset to perform all the duties of the alternative occupations the insurance company had identified.

With this additional evidence, added to the record in our appeal, the insurance company’s vocational expert agreed that Jim remained disabled. He was awarded all back pay owed, and will receive benefits going forward to age 67.

Victims Of Disability Should Always Appeal Unfair Claim Denials

In the end, because he continued to fight, appealing the insurance company’s denial of his disability claim rather than just accepting it as the final word, then filing suit when denied on appeal, our client was able to maintain his financial security.

Unfortunately, disability insurance companies unfairly deny legitimate claims every day, but anyone faced with an unfair claim denial should continue to fight and properly present stronger evidence on appeal or in court if necessary.

Our client deserved the benefits he had paid premium for over the years, and it was an honor to help such a wonderful physician and person overturn such an unfair claim denial.

Results may vary. Every case is different, and no outcome can be guaranteed.