New York Life Disability Claim Tips for Physicians
Our law firm has extensive experience handling New York Life/Cigna/LINA disability claims for physicians. Our attorneys understand how New York Life operates and what it takes to file a successful New York Life disability claim, and are happy to set up a free consultation to discuss your particular New York Life claim.
Below are some answers to the most common questions our attorneys receive from physicians about the disability claim process, generally, and their New York Life disability benefits, specifically.
Table of Contents
6. If I choose not to take medication or have surgery, will New York Life/Cigna deny my claim?
7. Will New York Life/Cigna take into account how my pain precludes me from working as a physician?
9. I am a physician and need to file a claim. Will New York Life/Cigna recognize my job duties?
11. Will New York Life/Cigna recognize my date of disability?
12. When should I contact an attorney about my New York Life/Cigna physician disability claim?
_____________
1. I am a physician with a Cigna/LINA policy. Why is my disability claim being handled by New York Life?
It is not uncommon for insurers to sell portions of their business, including group and/or individual disability insurance policies, to other insurers. As a result, the company you bought your insurance policy from might not end up being the one you interact with when it comes time to file a claim.
In December 2018, New York Life announced it had bought Cigna’s group life and disability insurance business for $6.3 billion. The new business was rebranded as New York Life Group Benefit Solutions.
The acquisition added approximately 3,000 employees and over 9 million customers for New York Life, making it one of the top five insurers across group life, accident, and disability insurance. Cigna and New York Life agreed to engage in a multi-year collaboration, with Cigna employees involved in the Group Insurance block transferring to New York Life.
2. Do New York Life/Cigna disability policies for physicians have “true” own occupation disability definitions?
New York Life/Cigna disability definitions can vary depending on when the policy was issued and the coverage selected by your employer, if you have an employer-sponsored plan.
Many employer-plans define disability as “any occupation” rather than “own occupation,” or change from “own occupation” to “any occupation” after a certain number of months/years (e.g. 24 months/2 years). However, there are New York Life/Cigna policies that offer own occupation coverage. For example, policy language from a New York Life/Cigna policy may read:
The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
- unable to perform the material duties of his or her Regular Occupation; and
- unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.
Here, insureds are able to work in another, unrelated occupation. That being said, offsets are part of many New York Life/Cigna group policies, so you should review your policy carefully to determine exactly how a new job may impact your benefits.
3. As a physician, how do I go about filing a disability claim under a New York Life/Cigna disability policy?
In order to file a New York Life disability claim, you must submit the proof of loss required under your New York Life/Cigna policy. Most physician disability policies require this proof to be submitted in writing and within a certain time frame—typically within 20 or 30 days from the date of loss.
New York Life allows claims to be initiated online, via New York Life’s website, or you can download the forms and submit them via fax, mail, or email. If you call to request claim forms or upon submitting a claim, our attorneys have observed that New York Life may subject you to an impromptu interview, so you should be prepared to answer important questions impacting your claim the very first time you are on the line with a New York Life representative.
If you are planning on having an attorney represent you on your disability claim, it is better to consult with counsel prior to making this initial call, so that you are not subjected to questioning before securing legal representation.
If you apply online, it is important to answer each question carefully and keep a record of what you submit. The initial proof of loss forms set the foundation for your claim, and you should not finalize or submit them unless you understand the ramifications of the type of claim you are making (partial v. total, etc.) and the date of disability you have selected (which can determine eligibility for benefits, and if you are even covered at all under an employer-plan).
4. What types of physician disability claims are most often challenged/denied by New York Life/Cigna?
While there are certainly claims that may not require attorney involvement—for example, a disability claim due to the loss of a limb or something very serious, such as paralysis—in our experience physician claims are not that straightforward.
Many of our clients have more nuanced conditions, such as slowly progressive musculoskeletal conditions due to degenerative disc disease. Others have conditions like a tremor, that may not prevent them from working in other jobs, but have a significant impact on their ability to work as a physician. Others have mental health conditions (anxiety disorder, panic attacks, PTSD) that cannot be verified by a single, definitive objective test.
Obviously, if your claim is denied or you have a dispute over policy interpretation, you may need an attorney to become involved to resolve the matter. That being said, lawsuits with insurance companies are often costly, stressful, and, in some instances, can drag out over several years, all to the insurance company’s advantage. Even if you prevail, it can be an exhausting process, and companies typically appeal, which can take at least another year or more, all the while you are not getting paid benefits.
In our view, it is more prudent to approach your claim carefully from the outset and have your attorney address any concerns that New York Life may have over the course of the investigation itself, so that you are not placed in a position where benefits have been cut off, you are not working and your only option is a lawsuit.
In our experience, the most common areas where complexities can arise in physician’s disability claims include:
-
- The timing of the claim (particularly in situations where a disabling condition is slowly progressive);
- Claims made by physicians with multiple sources of income, some of which may continue post-disability;
- Claims made by physicians who have taken an active role in office/hospital administration or are involved in non-clinical work;
- Claims involving alleged preexisting conditions;
- Claims where the underlying condition is difficult to diagnose or diagnosed by exclusion;
- Claims involving multiple co-morbid conditions;
- Claims involving conditions that are irregularly and unpredictably disabling;
- Claims involving pain/musculoskeletal conditions;
- Claims involving mental health conditions; and
- Claims involving recommendations for or against certain treatments or surgery.
5. Will New York Life/Cigna/LINA accept my doctors’ statements and medical records that support that I can’t practice medicine?
As part of most disability insurance claims, the insurer will require statement(s) from your treating provider(s) and medical records in order to confirm your disability and inability to work. But will they fully take into account what these records say?
Unfortunately, all too often, we see insurers cherry-pick statements from the records that support an adverse decision, or simply ignore medical records all together. One such example of this behavior is in the case McGuire v. Life Ins. Co. of N. Am., No. SACV2001901CJCJDEX (C.D. Cal. Sept. 21, 2022).
McGuire worked as a community relations manager when she suffered a fall at work that left her injured, with numerous complications including intense and chronic pain in her neck, pain in her shoulders, tingling and numbness in her right arm and hand, and pain in her right leg.
McGuire saw multiple doctors, both before filing, at the time of filing, during the plan’s elimination period and after. All these doctors noted McGuire’s pain and limitations, and several providers indicated that she was unable to work (and suffered from a reduced quality of life, loss of leisure activities, and impaired ability to do certain ADLs). MRI imaging showed foraminal stenosis, a herniated disc, fragments in the canal, debris including spur and disc with neurological compromise and cervical degenerative changes with marked right foraminal stenosis. An x-ray also demonstrated collapse in her spine. McGuire attempted various treatments including acupuncture, chiropractic care, medications, and injections but remained in significant pain and unable to return to work.
Despite this, Cigna/LINA had two physicians perform paper-only reviews of McGuire’s case, and both concluded that McGuire was not disabled under the terms of her policy. Cigna/LINA asserted that McGuire was not disabled because her gait was “normal,” the MRI of the cervical spine was consistent with age-related changes, EMG results were normal, and the fact she had declined to undergo surgery and did not take regular medications.
The Court found these doctors’ conclusions problematic for several reasons. First, neither doctor was a specialist in neurology, orthopedics, or pain. Second, the two doctors reached conflicting opinions regarding McGuire’s limitations (the first indicated that McGuire had no functional limitations, the second admitted she did have functional limitations, but only through part of the elimination period). The Court further determined that “LINA’s reliance on negative EMG results ignores the plethora of other objective evidence from, for example, x-rays and MRIs, that confirm McGuire’s subjective complaints of pain.” Finally, the Court found it reasonable that McGuire chose not to be on pain medication long-term and did not undergo surgery (although she did, at a later date, have the surgery).
This case demonstrates how insurance companies, like New York Life/Cigna/LINA, can ignore treating provider records or focus on a single statement or negative test result to attempt to undercut an entire claim. An experienced disability insurance attorney can help ensure your file is being properly evaluated by New York Life.
6. If I choose not to take medication or have surgery, will New York Life/Cigna deny my claim?
In some situations, surgery can be one of several treatment options, but for many reasons it may not be the ideal option for an individual (because of risks of surgery, chances of it not being a success or fully solving the issue(s), and/or cost). But will your insurance company still pay your long term disability insurance claim if you choose not to undergo a surgery?
Many policies contain care provisions, that have language that requires you to be under the ongoing care of a physician to receive benefits. The policy language may be as simple as this, or it may be more stringent. An example of a provision from a Cigna policy is as follows:
Appropriate Care means the Employee:
- Has received treatment, care and advice for a Physician who is qualified and experienced in the diagnosis and treatment of the conditions causing Disability. If the condition is of a nature or severity that it is customarily treated by a recognized medical specialty, the Physician is a practitioner in that specialty.
- Continues to receive such treatment, care or advice as often is required for treatment of the conditions causing Disability.
- Adheres to the treatment plan prescribed by the Physician, including the taking of medications.
In the case of McGuire v. Life Ins. Co. of North America, Cigna/LINA did specifically indicate in its denial of McGuire’s claim that her unwillingness to undergo surgery and take medication cut against her claim and showed that she was still able to work.
The Court found this argument unpersuasive, explaining that “contrary to Cigna/LINA’s suggestion, McGuire had tried medications (tramadol) and underwent injections, and that she “cannot be faulted” for declining to continue with oral pain medication, because of the risks of prolonged use. Further, the Court agreed that it was understandable that McGuire chose undergo a “significant spinal surgery” that “included nonnegligible risks of paralysis and death” and “with a meaningful likelihood that her symptoms would not improve.” However, not all courts have reached the same conclusions, and these cases can be very fact-specific to the nature of the condition and medical risks to the individual.
For many physicians, especially those with musculoskeletal conditions or other co-morbid conditions, surgery can be risky or have a strong likelihood that all symptoms won’t be resolved (e.g. when there are issues on multiple levels of the spine). If your insurer is predicating your receiving, or continuing to receive, benefits on undergoing surgery you should speak with an experienced disability insurance attorney to determine what options you may have.
7. Will New York Life/Cigna/LINA take into account how my pain precludes me from working as a physician?
Pain can be disabling but may not be easily objectively verifiable, particularly with musculoskeletal conditions. Even when imaging, such as MRIs, show abnormalities, it can be difficult to quantify exactly how much pain these abnormalities could be causing (and this might be even further complicated when multiple conditions are at play). Insurance companies, including New York Life/Cigna, may seek to downplay an insured’s subjective symptoms and reports of pain in order to deny or terminate benefits.
In Stratton v. Life Ins. Co. of N. Am., 589 F. Supp. 3d 1145, 1182 (S.D. Cal. 2022), Stratton, a senior executive partner (alternatively called a technology consultant) began experiencing “significant back pain” in 2011 and her condition continued to deteriorate until she filed a short-term disability claim, followed by a long-term disability claim, several years later with LINA.
At the time of filing, Stratton’s primary diagnosis was lumbar spondylolisthesis (however, later records diagnosed her with additional conditions including spinal stenosis and L4-L5 anterolistheis, degenerative changes in her hip, left knee osteoarthritis, and cervical spondylosis among others). While LINA initially denied her claim, it later approved it on appeal for the “own occupation” period of her claim but denied her claim after the “any occupation” period was reached.
Stratton’s treating physician opined multiple times that Stratton’s pain was disabling, numerous medical records corroborated spinal abnormalities, and two Functional Capacity Examinations (FCEs) supported her claimed limitations. Stratton underwent injections, was given prescription pain medication, used an inversion table, walked, and engaged in other movement therapies (such as yoga and Pilates). Further, Stratton saw two surgeons who told her that she should delay surgery as long as possible. But Cigna/LINA denied the claim regardless.
Stratton sued Cigna/LINA and the Court held in her favor, noting that “none of Defendant’s reviewers raise any concerns about Plaintiff’s credibility, yet they appear to have discounted, without reason, her subjective complaints of pain.” The Court also noted that Cigna/LINA focused on a record that indicated Stratton had a pain level of “zero” and one physical exam appointment; however, the Court determined that “Plaintiff’s failure to report her pain constitutes proof positive that she was not in chronic pain, particularly for an appointment that was not devoted to the relevant condition.”
In short, the Court here found Stratton persuasive, and that her subjective reports of pain were valid; however, this case shows the lengths that Cigna/LINA was willing to go to deny benefits. It also highlights how a policyholder’s credibility can be a key and decisive factor in these claims, as it is not difficult for insurers to find doctors willing to ignore subjective symptoms and cherry-pick medical records.
8. I can do some light exercise and Activities of Daily Living (ADLs), will New York Life/Cigna/LINA say I can still practice medicine?
Contrary to what many might think, you don’t have to be completely incapacitated in order to collect under your disability insurance policy, particularly if you have an own occupation policy. But this doesn’t always stop insurance companies from looking at whether a claimant can perform basic daily tasks and then extrapolating that they are still able to perform duties of medicine. This may be problematic for physicians suffering from certain musculoskeletal conditions – which actually might be improved by some physical activity.
In Stratton v. Life Ins. Co. of N. Am., 589 F. Supp. 3d 1145, 1182 (S.D. Cal. 2022), the Plaintiff, Ms. Stratton, became disabled due to multiple spinal conditions and excruciating back pain that prevented her from working (she had an own occupation policy that transitioned to an any occupation policy). As part of her reporting to Cigna/LINA, Stratton indicated that she was able to do basic chores, and that she walked, did yoga, and did Pilates in order to try and mitigate her pain. In their argument defending the claim denial, Cigna/LINA stated that the court should consider Stratton’s statements that she could use her computer “all the time,” walk up to three miles a day, do yoga and Pilates, and participate in multiple other “household and personal tasks.”
The Court found this argument less than persuasive, pointing out that Stratton’s physicians had prescribed a home exercise program, and that while she reported movement helped her pain, it never alleviated it.
We’ve seen insureds in similar situations where often insurance companies seek to argue that engaging in certain activities means that a physician can still practice. Disability insurance often engage in surveillance to try and “trap” insureds doing activities such as exercise and household chores in order to argue that their condition has improved enough to return to practicing medicine. This can be further complicated because often, for many musculoskeletal conditions, pain can decrease and functionality can improve somewhat after a physician stops practicing. If you feel that New York Life/Cigna/LINA is taking certain activities out of context, you should speak with an experienced disability attorney.
9. I am a physician and need to file a claim. Will New York Life/Cigna/LINA recognize my job duties?
Often, with individual disability insurance policies, total disability, in part, will be defined by the inability to do the “substantial and material duties” of your regular occupation. Disability insurance companies may not understand, or willfully seek to misclassify or over-simplify, your job duties—which could mean the difference between collecting on your benefits and a claim denial.
For example, in Joyce v. Life Ins. Co. of N. Am., No. 2:18-CV-1293 (W.D. Pa. Feb. 10, 2021), the plaintiff, Mr. Joyce was a garbage-collection supervisor, or route manager. He was struck by a tree branch during a storm and suffered a concussion, which resulted in cognitive dysfunction, vision problems, headache, frustration and visuospatial difficulties. As a result of his injury and subsequent symptoms, he was no longer able to perform his job duties and had to file and disability insurance claim with Cigna/LINA.
Joyce’s job duties included supervisory activities, problem analysis and solving, interactions with other workers and equipment knowledge. However, Cigna/LINA classified Joyce as only a “laborer” and decided that Joyce was still able to perform this job. Further, they relied on a paper file review of Joyce’s medical records in order to deny him benefits.
The Court, after reviewing the case, decided that Cigna/LINA did not correctly consider Joyce’s true job duties and that they had been only selective in what records they chose to review to reach the decision that Joyce was able to still work. The Court remanded the case back to Cigna/LINA to re-evaluate the claim using Joyce’s correct job definition. Unfortunately, it took a lawsuit for Cigna/LINA to evaluate the claim as it should have from the beginning.
In the case of physicians, insurance companies will often try to identify broad or general duties in order to deny claims. For example, they may claim that a specialist is actually a general practitioner, and thus is still able to perform the duties of this job. For example, they may seek to classify a cardiovascular surgeon as a general surgeon, ignoring the specifics of the occupation that may make it more difficult practice.
An experienced disability insurance attorney can help make sure that New York Life/Cigna/LINA is properly evaluating your job duties.
10. I didn’t receive the policy my agent promised me. Can I sue New York Life/Cigna if they deny my benefits?
In some instances, we’ve seen scenarios where insurance agents make certain promises and insureds later find out they didn’t get the coverage they thought they did when it comes time to file a claim.
In Trujillo v. New York Life Ins. Co., No. 308CV000506LRHRAM (D. Nev. July 23, 2009), Dr. Trujillo, a chiropractor bought three New York Life policies in 1989. In 1990, Dr. Trujillo suffered from two lower back disc herniations, which were later exacerbated by numbness and pain in his upper extremities. Between 2000 and 2004, as a result of his injuries, Dr. Trujillo stopped working as a chiropractor, sold his practice and took a less physically demanding job. Dr. Trujillo filed a claim; however, New York Life denied the claims and refused to pay benefits, causing Dr. Trujillo to need to see patients again.
Dr. Trujillo sued New York Life and his insurance sales agent, Roger Wolfe. Trujillo alleged that Wolfe promised Dr. Trujillo that New York Life’s policies offered “the most liberal definition of disability offered by any company” and that benefits would be paid if he was unable to work as a chiropractor, even if he obtained another job. New York Life had numerous arguments in the case, including that Dr. Trujillo was barred by the statute of limitations because, in part, Dr. Trujillo should have reasonably discovered the fraud either in 1990 (when he purchased the policies) or in 2004 (when his claim was first denied).
The Court was not persuaded by these arguments, finding that from 2004 to 2007 Dr. Trujillo may not have discovered the alleged fraud because he was meeting New York Life’s requests for information and explaining “[t]he fact that New York Life continued to solicit information from Trujillo until 2007 could have indicated that New York Life intended to honor Trujillo’s claims.” Furthermore, the Court found that New York Life did not issue a final decision until January 25, 2007 (thus, the statute of limitations would potentially be tolled until that date).
While this case was allowed to move forward, it is just one scenario and underscores the importance of not relying solely on your agent and carefully reading your disability insurance policy when you receive it, to make sure you have the coverage you were expecting.
11. Will New York Life/Cigna recognize my date of disability?
In some instances, there may be a disagreement on the exact date a claimant became disabled (and therefore becomes eligible for benefits). This can be crucial to a claim and could impact years of benefits, or even whether or not a claimant is eligible to receive total disability benefits.
In Berg v. New York Life Ins. Co., 831 F.3d 426 (7th Cir. 2016), the plaintiff, Mr. Berg, was a pit broker who became disabled based on an essential tremor. His tremor first manifested in 2005 and it eventually forced him to leave his job in September 2007 because he was no longer able to write quickly and legibly. However, it wasn’t until February 2010 that he was diagnosed with an “essential tremor” by a neurologist. Berg was awarded benefits, with an onset date designated as February 3, 2010 (rather than September 2007 when he ceased work).
Because of this date Unum (who was administering the claim for New York Life) determined that Berg was only eligible for residual disability benefits because his regular occupation was that of an “unemployed person” on February 2010. Berg sued, seeking benefits from September 2007 and for a designation of “total disability,” for the purposes of future benefits.
Here, the Court explained that the case hinged on the meaning of one phrase in the policy, that the disabling condition “requires and receives regular care by a Physician” and whether this clause contained a temporal element. In its interpretation of Berg’s New York Life policy, Unum argued that Berg did not receive “care by a physician” until February 3, 2010 and, therefore, he did not have an “illness or sickness” until then. The Court did not buy this argument, explaining “[t]his syllogism might hold up in the rarified atmosphere of formal logic, but it disintegrates when exposed to the corporeal world.”
The Court went on to provide hypotheticals, such as the insured who discovers a lump in her breast but can’t see a doctor for several months and only then is told she has stage 4 cancer. Or the insured who falls down the stairs into his basement, severing his spinal cord and rendering him a paraplegic, but, as a doomsday prepper, is able to survive for a long period of time in the basement before he is discovered and receives initial treatment from a physician. The Court points out that in each of these examples, the person is clearly disabled or ill without regard to the timing of the visit to the physician.
This case shows the arguments that insurers, including New York Life, may make to deny or limit benefits by trying to establish a later date of disability.
12. When should I contact an attorney about my New York Life/Cigna physician disability claim?
Physicians who are considering filing a claim for disability insurance benefits should meet with a disability attorney well-before submitting a claim.
Each disability policy has different, complex language that insurance companies may manipulate to circumscribe and restrict coverage. Before filing, physicians should make a coordinated effort, with an attorney’s assistance, to determine whether their particular claim is covered, and if so, how that claim is best presented to ensure payment.
The information provided above is offered purely for informational purposes. It is not intended to create or promote an attorney-client relationship, and does not constitute and should not be relied upon as legal advice.
Every claim is unique and the discussion above is only a limited summary of information that may be relevant to your claim. If you are concerned that New York Life is not handling your claim fairly, an experienced disability insurance attorney can help you assess the situation and determine what options are available to you.
Notable New York/Cigna/LINA Life Disability Insurance Cases
Reynolds v. Life Ins. Co. of North America, No. C21-1424 TSZ (W.D. Wash. Dec. 18, 2023)
Poinsett v. Life Ins. Co. of North America, Case NO. CIV-21-1205-F (W.D. Okla. Sept. 20, 2022).
Joyce v. Life Ins. Co. of North America, Civil Action NO. 2:18-cv-1293 (W.D. Pa. Feb. 10, 2021).
Berg v. New York Life Ins. Co., 831 F.3d 426 (7th Cir. 2016).
Trujillo v. New York Life Ins. Co., No. 308CV000506LRHRAM (D. Nev. July 23, 2009).
Scanlon v. Life Ins. Co. of N. Am., No. 22-1121 (7th Cir. Aug. 31, 2023).
Notable New York/Cigna/LINA Life Disability Insurance Blog Posts
Cigna Sells Group Disability to New York Life
New York Life Buys Group Disability Business from Cigna
Cigna Seeks to Sell Group Insurance Business
Disability Insurer Profiles #3: Cigna/LINA
ABC News Investigates CIGNA’s Disability Claims Handling Practices
Cigna Denies Breast Cancer Survivor Disability Benefits
The Devil Is In the Details: Long Term Disability Policies and Benefit Offsets
