Many disability claims turn on complicated medical questions or difficult issues of insurance policy interpretation. Sometimes, however, a claim is derailed by something far more basic: a simple mistake.
The Client’s Medical Condition
In this case, Robinson Warncke represented a client with a rare bleeding disorder that caused a hemorrhage within her spinal cord. Spinal cord bleeding frequently leaves scar tissue that irritates the spinal cord and nerves, resulting in chronic neurological symptoms. Our client was left with severe back pain, neuropathy, significant balance problems and falls, bladder numbness, migraines accompanied by vomiting, profound fatigue, and debilitating brain fog. Despite these symptoms, she continued working for several years before ultimately being forced to stop and file for disability benefits.
Initial Approval of Disability Benefits
New York Life (originally Life Insurance Company of North America) approved her claim and paid long-term disability benefits for more than two years. More importantly, it approved her claim under the more demanding “any occupation” definition of disability that typically applies after the first two years of long-term disability benefits.
The Challenge
The problem arose during that review.
The physician who approved our client’s claim prepared a medical report describing her physical restrictions and limitations. In disability claims, those restrictions are compared to the physical demands of the claimant’s occupation—or, under an “any occupation” definition, to occupations the claimant could reasonably perform. In our client’s case, that meant determining whether she remained capable of full-time sedentary work.
The physician’s report stated that our client was limited to only occasional sitting, standing, walking, lifting, carrying, pushing, and pulling. In vocational terms, “occasional” generally means no more than one-third of the workday. Someone who can sit for only two to three hours during an eight-hour workday cannot perform full-time sedentary employment.
Unfortunately, the physician’s report was poorly worded. The placement of the word “occasionally” made the sentence difficult to read, creating the potential for a reader to mistakenly conclude that our client was unrestricted in sitting and merely limited to sedentary activities.
That is exactly what happened.
Approximately one year later, a New York Life nurse reviewed the report and mistakenly interpreted it as concluding that our client could perform full-time sedentary work. The nurse then contacted each of our client’s treating physicians, informing them that New York Life had determined she could return to work and asking whether they agreed.
Her physicians disagreed.
Instead of recognizing that everyone involved—including the original reviewing physician—actually agreed our client was disabled, New York Life concluded there was a conflict of medical opinion and ordered an Independent Medical Examination (IME) to break the supposed tie.
In reality, there was no conflict at all. The entire dispute resulted from a misunderstanding of the original report.
Unfortunately, the IME became the turning point in the claim.
The examining physician spent only about twenty minutes with our client, much of that time gathering her medical history because he had conducted little meaningful review of her records beforehand. His report reflected only a cursory review of her extensive medical history and contained little discussion of her longstanding neurological symptoms or objective medical findings.
Based primarily on a brief physical examination, the IME physician concluded that our client could sit constantly, stand and walk occasionally, and lift ten pounds occasionally—in other words, that she met the physical demands of full-time sedentary work. Relying on this opinion, New York Life terminated her disability benefits.
The Appeal Strategy
Robinson Warncke represented the client during her administrative appeal. After reviewing more than 6,000 pages of claim materials, we identified the misunderstanding that had triggered the entire sequence of events and made it the centerpiece of our appeal.
We explained that the IME—and ultimately the claim termination—would never have occurred had New York Life correctly interpreted its own physician’s original report.
To objectively establish our client’s physical limitations, we obtained a Functional Capacity Evaluation (FCE), widely recognized as the gold standard for measuring work capacity. The testing confirmed that our client possessed significantly less than sedentary work capacity. She was incapable of constant sitting and could not even meet the minimum lifting requirements of sedentary employment.
We also submitted detailed statements from our client, witness testimony from those who observed her daily functioning, treating physician opinions, and comprehensive symptom diaries documenting the ongoing effects of her condition.
Our appeal explained that although IMEs can sometimes provide useful evidence, the IME in this case deserved little weight because it was based on a superficial examination, minimal record review, and conclusions that conflicted not only with every treating physician but also with New York Life’s own earlier medical review. The FCE, by contrast, provided objective testing that confirmed what the medical evidence had consistently shown all along.
The Result
Faced with overwhelming evidence of disability—and the clear mistake that had set the claim on the wrong course—New York Life reversed its decision and reinstated our client’s long-term disability benefits.
Why This Case Matters
This case illustrates an important lesson about disability appeals. Not every wrongful denial results from a genuine disagreement over the evidence. Sometimes a claim goes off course because of a misunderstanding, a poorly worded report, or an administrative error that snowballs into a termination of benefits. Identifying the true source of the problem requires a meticulous review of the claim file and a thoughtful strategy for correcting the record.
How Robinson Warncke Can Help
At Robinson Warncke, we carefully examine every disability claim to determine not only whether the insurance company reached the wrong conclusion, but also how it got there. That attention to detail often uncovers issues that others overlook—and can make the difference between a denied claim and restored benefits.
