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The 7 most common reasons Long Term Disability claims are denied.

Appealing for benefits is best done under the guidance of an experienced disability lawyer.

What are the main reasons a Long-Term disability insurance company would deny my claim?

Author: Attorney Lonnie Roach


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).


Denied LTD claims

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. An ERISA LTD attorney explains.

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.


  1.   Inadequate Medical Evidence.
  2. 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.


  3.   Missing medical records.
  4. 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.


  5.   Missing doctor’s statement.
  6. 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.


  7.   Not meeting the insurance policy definition of disability.
  8. 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”.


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  9.   Some conditions are excluded from coverage.
  10. 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.


  11.   Video surveillance reveals inconsistencies in your claim.
  12. 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.


  13.   Missed deadlines.
  14. 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.


How do I avoid making mistakes in my LTD claim?

Author: Attorney Lonnie Roach

According to the Council for Disability Awareness, one out of 4 people currently in their 20s will be disabled before they retire. Most people think “It will never happen to me,” but the possibility of sustaining an injury or contracting an illness that prevents you from working always exists.


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Don’t make these mistakes in your LTD claim. A successful Texas disability lawyer explains easy ways to avoid common pitfalls for claimants. Call 512-454-4000 for help with your LTD or SSDI disability claim today.

The average period of absence from work when a person becomes disabled is 34.6 months or almost three years. Some people can rely on savings to pay for expenses for a few months, but few can afford to live for years without income. Disability insurance can provide much needed income during this time, but consumers should be aware of the benefits and restrictions of any policy they purchase.


Short term disability insurance (STD) pays a percentage of your salary if you become temporarily disabled.

Examples of conditions that short term disability insurance covers are pregnancy, back injuries, and digestive disorders. Benefits last between three and six months and have a “cap,” a maximum benefit per month, as well as a limit on the time you can receive benefits.


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.


Long term disability insurance (LTD) typically pays between 50-60% of your salary and benefits continue until you return to work, or for the number of years stated in the policy.

Some insurance policies will cover an employee until they are 65. If the applicant has a short term plan, LTD will take effect when STD benefits run out; otherwise, there is a 3-6 month waiting period before benefits begin. Both STD and LTD policies are usually part of an employee benefit plan, but can be purchased by an individual. If the policy is paid for with pre-tax dollars, as in an employer based group plan, benefits will be subject to income tax. If the plan is purchased by an individual with after tax dollars, benefits will not be taxed.


While an LTD policy purchased by an individual is governed by state law, employer sponsored LTD plans are usually governed by ERISA (Employee Retirement Income Security Act), a federal law that was enacted to protect employee rights to benefits.

ERISA disputes can be drawn out as ERISA requires a claimant to exhaust all their administrative remedies before filing a federal lawsuit. ERISA claims are very different from typical insurance claim. These claims are governed by federal law, and disputes are litigated in federal court. Policy holders who have ERISA claims would be well-advised to hire an experienced, ERISA attorney, should they be denied.


Policy holders whose claim has been denied have 180 days to appeal.

In ERISA claims, the appeal process is crucial. It may be the only opportunity to ensure the record contains the evidence necessary to win the case in court. In most instances, the court record cannot be supplemented after the appeal process ends. After the appeal is filed, the insurer then has up to 90 days to consider the appeal. If an appeal is denied, the claimant’s only remaining option to pursue benefits is to file suit.


Long term disability lawyer

Successful Texas attorney Lonnie Roach.
Highly experienced in ERISA LTD claims.

If you are approved for LTD benefits, the insurer will require you to file for Social Security Disability Income as well and offset any amount received from Social Security against the LTD payment.

Regardless of whether an LTD is under an employer sponsored plan or purchased individually, there are several things to watch out for in any disability claim.

Know the insurer’s precise definition of “disabled” or “partially disabled.”

Typically, “totally disabled” means unable to perform duties of your occupation due to illness or injury; “partially disabled” may provide benefits if you can no longer work at an occupation, but can work full or part-time at another job.


Understand the policy’s requirements and limitations.

Most employer-sponsored plans require the claimant to be working full-time at the onset of illness or injury. Full time usually means 30-35 hours per week; check the policy for its definition of “full time.” There may be exclusions for pre-existing diseases (illness or injury diagnosed and/or treated within a period before the policy benefits begin). Some LTD policies exclude particular accidents or diseases and many include a 24-month limitation on disabilities caused in part by drug abuse, alcoholism, mental or nervous conditions.


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Know the time limits that apply for eligibility in the policy.

Most insurers have time limits on the waiting period, notice of claim, providing proof of loss, exhausting administrative remedies and filing suit. If possible, file the claim while you are still working. If you quit, the employer or insurer may claim you are no longer covered by the plan.


Work closely with your treating physicians and keep accurate records.

It is imperative to provide strong evidence for proof of disability. Get regular treatment from medical provider(s) experienced in your condition or illness and continue treatments while receiving benefits. Make sure medical providers are charting all symptoms and restrictions, including those not totally disabling by themselves. Each impairment has an impact on your disability, even those that existed before the disabling condition.


Be prepared to provide documentation to insurers throughout the claim process.

All phone conversations and other communications with the insurer should be documented in writing. Any documents and correspondence sent by mail should be sent certified mail, return receipt requested.


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.


best social security disability lawyer
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.


5 star disability lawyers

"Words can not truly express the gratitude that I feel toward Mr. Lonnie Roach and his professional team. I give them an A+++. Very compassionate and prompt. Their priorities are first and foremost helping you succeed at your case. When you feel helpless, feeling like someone is on your side can mean the world to you. Thank you for working for the people."
-Amy K.


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top disability attorney

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Attorney Lonnie RoachAuthor: Attorney Lonnie Roach has been practicing law for over 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion rated by Martindale Hubbell. Through his extensive litigation Mr. Roach obtained board certifications from the Texas Board of Legal Specialization. Lonnie is admitted to practice in the United States District Court - all Texas Districts and the U.S. Court of Appeals, Fifth Circuit. Highly experienced in Long Term Disability denials and appeals governed by the “ERISA” Mr. Roach is a member of the Texas Trial Lawyers Association, Austin Bar Association, and is a past the director of the Capital Area Trial Lawyers Association (Director 1999-2005) Mr. Roach and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.

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