New York Life prides itself on being “the company you keep.” However, if you rely on them to pay a long-term disability insurance claim under ERISA, they often do not want to keep you. Instead, they will do whatever they can to skew the playing field in their favor and deny your claim.
The law gives you the right to appeal, although the appeals process has some built-in advantages in favor of New York Life. Nevertheless, you can and should appeal a benefits denial when your policy demands that you receive payment.
The law office of J. Price McNamara ERISA Insurance Claim Attorney does not hesitate to stand up to the New York Life Insurance Company.
We regularly obtain benefits and settlements for clients with disabilities from major insurers who refuse to pay valid claims. Let us help fight for the benefits you deserve from New York Life.
When dealing with a company like New York Life, there is no room for error. Your long-term disability claim can be worth millions of dollars, depending on your age and salary, and you should take no chances. Companies like New York Life err on the side of denying any claim that seems close, and the slightest mistake can force you into the appeals process.
It is essential to have all your bases covered when you complete your application for long-term disability benefits. The insurance company will go through your claim extremely closely, looking for any reason they can deny it. The main thing the insurance company cares about is whether you can work. At first, their question will be about whether you can perform the duties of your current job.
Here are some things to consider when you file your initial claim for benefits:
Hiring an insurance attorney can help you present a more compelling claim from the very beginning.
You can expect the insurance company to go to great lengths to understand your current situation, meaning they are looking for a basis to deny your claim. Insurance companies will assign an investigator to your claim
That investigator may:
Federal court judges have reviewed the actual life of the claimant. If a judge gets to this point, it may not bode well for your claim. Therefore, you need to take care when applying for benefits and receiving them. It is not an exaggeration to say that you should always act like the insurance company is looking because it probably is.
Insurance companies occasionally change the rules as time passes. Some claimants have their initial benefits claim granted, only to have them cut off after some time passes.
Insurance companies will often change the definition of disability after several years to exclude benefits for claimants who can still do some work instead of just the work they were doing before their illness or injury.
It does not matter what you are trained for because an insurance company will use any excuse possible to save money. You can also challenge the termination of benefits just as you will an initial denial.
If the insurance company denies your initial claim for benefits, you can appeal the decision. This process is where ERISA does not exactly work in your favor. When an insurance company denies your workers’ compensation claim, you can immediately go to a third party for an objective review of your case.
When an insurance company denies your long-term disability claim, you have to go to them first to review their denial. While they promise that they will take a fresh look at your claim, they will essentially get to say no to you twice – only the second time, they are covering themselves that much more.
Nonetheless, appealing to the insurance company first is required by ERISA. You cannot take your case to a judge until you have gone through the insurance company.
Not only must you appeal to the insurance company, but you must treat this step seriously. Of course, the insurance company may revisit its own decision, but you should not expect it. The process is favorable to the insurance companies, but you have something going for you because you can hire a disability insurance lawyer who can fight back on your behalf.
When you file an appeal at the insurance company level, you will build a record for their consideration.
This record will include:
The insurance company must make available to you the reason for the claim denial and the exact information the adjuster used in reaching the decision. New ERISA rules now require the insurance company to be far more transparent. Insurance companies can get in trouble for flouting these new regulations.
Err on loading the record with as much information as possible to support your claim. You never know what may persuade a judge, even if the insurance company is locked into its position already.
When you appeal to the insurance company, you should act as if your ultimate audience is the judge because they are the person who will likely be the ones granting your benefits.
The record is largely locked down once you go through the insurance company appeals process. If you take your case to federal court, the judge will be limited to reviewing the same thing that the insurance company saw. You cannot build a new record for the judge, and they are only allowed to ask for more information under limited circumstances.
Even though federal judges may only rule on the Administrative Record, you can expect that they will give it a close review. One major thing that the judge will review is your current life and whether you are disabled under the policy terms. If you can establish that you meet the plan’s definition of disabled, you may recover long-term disability benefits.
Federal court is where your lawyer will humanize you and tell your story. Even if you cannot add information to the file, your lawyer will still have a chance to present your case to the judge in a written brief and then in a hearing if the judge decides that is necessary.
It is one thing to have medical records in front of a judge. It is another thing to explain how your disability affects you and why the insurance company was wrong when they said that you were not disabled.
Here, the insurance company has some power. They are the ones who can define the term in your policy. They may even change the rules after you have been receiving benefits for a particular time.
Insurance companies will even include language in the policy, which gives them discretion. When that happens, the court must use a standard of review that gives some deference to the insurance company’s initial decision.
However, a federal judge can spot a subjective and self-interested rationale for denying you benefits and can overturn what the insurance company has done.
Although there are hurdles and challenges in the appeals process, it does not mean that insurance companies have the absolute right to do whatever they want. The language of the policy still binds them because it is a contract. Both your long-term disability policy and ERISA afford you some rights.
One reason why New York Life has lost ERISA long-term disability appeals in court is that the company has not used independent medical evidence as a basis for denying a claim. The company will have its in-house physicians dependent on the company for their business.
These doctors will look at your records and decide without ever examining you. They will claim that they know better than your treating physician who has seen you in person, but these doctors are not truly independent.
This kind of loss is precisely what happened in a federal case in which a judge overturned New York Life’s termination of long-term benefits for a nurse. When the seriously injured nurse, injured in an automobile accident, claimed that she could no longer work, the insurance company gave no weight whatsoever to the opinion of the claimant’s physician.
Instead, New York Life relied on the opinion of a vocational expert who found that the claimant could work, even though the expert never spoke with or saw the claimant. If the insurance company is going to reject the treating physician’s opinion, they need to have a more sound basis for doing so.
Another reason why companies like New York Life lose appeals in court is that they cherry-pick evidence that works in their favor while ignoring compelling proof of your disability. They like to pick and choose what helps them because they do not want to pay you.
In filing an appeal, a judge will look at the entire record. Even under a standard of review that is more favorable to the insurance company, a judge may still find that the insurance company’s decision was arbitrary.
A long line of legal decisions shows that insurance companies are willing to go the distance in fighting your claim. When you think about it, you can understand why. If you get a substantial portion of your salary for an extended time, your claim can cost the insurance company millions of dollars over its life.
If they lose in court, they will also need to pay you back benefits (and perhaps even your attorney’s fees). They have every reason to continue to fight. Many cases will even go to a federal appeals court when the insurance company loses at the district court level.
Therefore, when you appeal the denial or termination of your benefits, you should prepare to fight. You do this by hiring an experienced long-term disability insurance attorney.
A lawyer knows how to tell your story and make your case to the insurance company and the judge. In many long-term disability claims, the insurance company becomes your adversary, so you should view them that way from the start.
Price McNamara ERISA Insurance Claim Attorney regularly take on powerful insurance companies like New York Life to get our clients the benefits they deserve. We are not afraid of large companies, and they must answer in court just like anyone else.
To learn more about the legal side of filing an ERISA claim and how an experienced disability insurance lawyer can help, call us at (504) 420-6962 or contact us online. The insurance company may have power, but there are also limits on what they can do.
This has been a very difficult time for myself and my family. Mr. Mcnamara did his best to be as empathetic and compassionate as possible. He is very knowledgeable and a man of great integrity.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts