What Can You Do If Your Long Term Disability Insurance Claim Has Been Denied?

If your long-term disability insurance benefits have been denied, you can fight back, but you need experienced representation. Insurance companies have limitless resources of attorneys, doctors, and claims managers whose focus is on limiting exposure by denying claims. The laws governing LTD policies favor insurance companies and are not easily navigated. Often, you must submit your entire case on appeal, or be limited in what you may offer in Court.

Why is it so hard to challenge an LTD denial?

LTD policies issued through an employer are governed by a federal law known as ERISA which restricts claimants to an administrative appeal conducted according to strict rules. If the appeal is denied, the next step is going to federal court. The appeal has to be prepared for both the administrative appeal and federal court and the Judge who will decide these cases – NOT a jury.

If you purchased your policy privately and your appeal is denied, you have the option of pursuing a lawsuit in state court once you have exhausted any administrative remedies. Like the ERISA appeal, the appeal for an individual policy must be aggressive and thorough to support any and all claims that may wish to be pursued – including often bad faith.

Resending materials previously submitted will almost certainly fail to meet the challenges. Rather, you’ll need to bolster your appeal with an over-abundance of materials that anticipate as many challenges as possible and operates to undercut their positions.

Among the most common reasons for denied long-term disability benefits:

Missed deadlines. Locate your original policy and find the specific provision regarding the time allowed to respond to a denial. Don’t rely on your insurance broker or HR department. The language in the policy is a legal contract. If it says you have 180 days to respond from the date of the correspondence, that’s it. Cases have been denied when the person missed the deadline by 24 hours.

The medical condition does not meet the policy definition of a disability. A report from your doctor stating that you are unable to work is not enough. Medical records must show an established illness or injury, clear notes indicating the tasks related to your occupation that can no longer be performed and reports documenting physical or cognitive limitations. Often, frequency of treatment is an issue raised.

Medical records fail to demonstrate consistent care. Even in cases where ongoing care may not be medically necessary, evidence of on-going care provided by a treating physician or specialist is needed to document a disability.

Disability does not preclude occupation. The average person would not think to include an occupational evaluation of their job in a long-term disability insurance claim, but this is needed to document the tasks associated with their job. To properly support the claim, a surgeon syndrome must outline with great specificity the need for exceptional manual dexterity, hand-eye coordination, stamina to stand for hours during surgery, cognitive focus, etc.

Any occupation versus own occupation. Depending on the policy, you may have insured your occupation as a dentist, but the insurance company may determine that you are still able to act as a manager of a multi-dentist practice. The policy may also pay benefits for “own occupation” for twenty-four months and then switch to “any occupation.”

Failure to provide requested information. Insurance companies are excellent at hiding. Materials sent by email or snail mail are lost, the claims manager was transferred and no one has been assigned the case, or the entire department has been moved to the fourth floor and no one can find the documents. Every piece of documentation sent to the insurance company must be sent via express mail with a signature required to show proof of delivery, but sometimes even that is not enough. Emailed and express mailed documents from lawyers are less likely to go missing. This is not how it should work, but it is often the case.

Failing to comply with medical treatment. Yes, the insurance company can insist on claimants undergoing medical treatment prescribed by its doctors and deny benefits to people who refuse the recommendations. Here’s an example: a dentist has severe carpal tunnel syndrome in both hands and can no longer perform the duties of her profession. She has had surgery for her right hand and it was not effective. The long term disability insurance company’s medical team has reviewed the dentist’s medical records and concluded that another surgical procedure would correct the problem. She is presented with the option of having the surgery or having benefits cut off.
Claimants should prepare for unexpected responses when filing for long term disability benefits.

A long-term disability insurance claim is not like a homeowner’s claim or an auto claim because they are not one-time benefits. A professional with a $8,000 monthly benefit at age 40 presents a significant exposure to even the largest insurance company, when taking into consideration the number of policies sold. It is in the insurance company’s best interest to either deny or limit the claim.