What are the main reasons a Long-Term disability insurance company would deny my claim?
According to the Department of Labor, from 2006 to 2010, long-term disability claims accounted for 64.5% of ERISA employee benefits litigation. Most long-term disability insurance plans provided by employers are governed by the Employee Retirement Income Security Act of 1974 (ERISA).
Long term disability claims evaluated by insurance companies can be denied for any number of reasons, even in cases where a disability is clearly evident.
It’s not unusual for an insurance company to delay or deny long-term disability claims based on suspect reasoning, but over time, patterns emerge. Understanding the most common reasons given for denials of long-term disability claims may help you in filing a successful claim.
- Inadequate Medical Evidence.
- Missing medical records.
- Missing doctor’s statement.
- Not meeting the insurance policy definition of disability.
- Some conditions are excluded from coverage.
- Video surveillance reveals inconsistencies in your claim.
- Missed deadlines.
A claimant must prove he/she is receiving treatment from a medical provider on a regular basis. If you have a disability, you are expected to see a doctor or therapist on a regular basis. Similarly, if you have a psychiatric condition, you should be able to show that you are seeing a psychiatrist or psychologist. You must also provide proof of objective tests such as MRIs, x-rays, and lab tests when appropriate. If there are no exams, laboratory tests, evaluations or medications to support the claimed impairment, the insurance company is likely to deny your claim.
Sometimes an insurer does not obtain all your medical records. In this situation, find out what records the insurance company requested and which records were received. Make sure the insurance company requested all of the documentation supporting your claim and those records were received.
If you have been denied disability don’t give up! Contact a Disability lawyer at 512-454-4000 for a free consultation and get the benefits you deserve.
Often, the most important piece of evidence in proving a disability claim is a written statement or opinion from a doctor detailing your disability and how it affects your ability to work. Many doctors find these statements or forms to be burdensome and annoying. If you are asking your doctor to set aside time to complete the forms for you, you should offer to pay for that time. Time is money to doctors, just like to everyone else. If your doctor is unwilling to provide a statement or complete insurance company forms, you may need to find another doctor.
Each long-term disability insurance policy has a specific definition of “disability” which the policy holder is required to meet. These definitions vary considerably. Under an “own occupation” definition, a person is disabled if they are unable to carry out the duties of their particular job. Under an “any occupation” definition, disability is defined as the inability to perform the duties of any job. Some LTD plans transition from “own occupation” to “any occupation” after 24 months or a certain length of time. You should always get a copy of your policy and read your particular definition of “disability”.
Long-term disability insurance policies often exclude certain conditions from coverage, such as drug or alcohol abuse. Other conditions such as depression or self-reported conditions may be limited to coverage of 24 months or less. Pre-existing conditions are also usually excluded from coverage. Once again, these provisions vary considerably. You should obtain—and read—your policy.
An insurance company may hire an investigator to follow you and record you participating in activities that appear to conflict with your claim and try to prove that you are not disabled. In most cases, a person has “good” days and “bad” days and a surveillance video may portray you on a “good” day.
Note all filing deadlines and the appeal deadline on your initial denial notice. You usually have 180 days to appeal an initial denial; if you miss the 180-day deadline, your options to sue an insurer in federal court are likely lost. Submit all medical records and documentation as soon as possible. Federal courts in ERISA cases are only allowed to consider evidence in the administrative record. The administrative record is anything an insurer or administrator looks at when deciding whether or not to pay a claim. This includes medical records, reports, bills, statements, and claim-related correspondence, as well as “peer review” reports, independent medical exams, and transferrable skills analyses provided by the insurer. Once a lawsuit is filed, the court’s review is confined to the administrative record and the court is rarely permitted to consider evidence outside the record.
Prepare to be Googled
The ease of conducting a low level investigation over the internet has led long term disability companies to regularly resort to Google searches to check on their disability insurance insureds.
Most people don’t worry too much about it as they are legitimately disabled and feel that any investigation will only serve to verify their condition. Of course, this also depends on the accuracy of the things being posted about them and whether they are in the proper context. This also lies on the insurance companies’ honesty, how and if they evaluate an information rather than use it to their advantage.
Unfortunately, one cannot simply trust the internet when it comes to judging the integrity of an insurance company or the accuracy of any statement found posted.
Therefore, those with ongoing disability claims should regularly Google themselves and see what they find. They should also constantly monitor social media posts, including photographs, to make sure that none contain any inaccurate or misleading information that may reflect on their disability or even ability to work.
Many disabled insureds find themselves being questioned by their insurance carriers about small businesses where they seem to hold some type of ownership.
For example, a DBA (Doing Business As) certificate identifying an insured is likely to be discovered, leading to an investigation on his involvement in a business and his apparent ability to work after all. Some insurance companies even review Church websites to see if an insured with long term disability is involved in certain activities. Most people who are disabled continue to lead productive lives and want to discover what they can do despite their disabilities. Unfortunately, there are insurance companies that try to use this desire to their advantage, their reasoning being that if one has the ability to work, he has no right to collect disability benefits.
When it comes to seeking additional income, most disability plans not only allow for such a limited return to the workforce, they encourage it.
However, any attempt to make such a foray into the workforce on the sly in this Internet age will most likely lead to a conflict between you and your insurance carrier.
ERISA was enacted to protect private pension and health plans from fraud and mismanagement, but because the Act’s regulations preempt similar state or local laws, they may deprive individuals of protections provided by “bad faith” laws.
ERISA and state “bad faith” laws are highly complex. If your long-term disability benefits have been denied, do not hesitate to seek legal advice. Bemis, Roach and Reed has successfully handled cases against: The U.S. Government, Aetna, Cigna, Unum, Hartford, Metlife, Prudential, Standard, Connecticut General Life, Life Insurance Co. of N.A. , Lincoln Financial, Northwestern Mutual, Reliance, Assurant, CNA, Fortis, Liberty Mutual, Paul Revere, and many others.
Disability benefits are an important source of income for those who are unable to work. If you not able to work due to accident or illness, you may be eligible for Social Security Disability or Long Term Disability benefits. If you have applied for benefits and been denied, contact the attorneys at Bemis, Roach and Reed for a free consultation. Call 512-454-4000 and get help NOW.
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