You filed for Long Term Disability and just found out that the insurance company has denied your claim. Yet you know that you cannot work and your doctor agrees. How could this be? Why do insurance companies deny short or long term disability claims? Why do they abruptly terminate LTD benefits while you still need them? Frustrating as it may be, after paying your premiums and then finding yourself unable to work, insurance disability denials are quite common.
There are pretty common reasons for denial or termination of long term disability claims. However, long term disability denial letters are often hard to decipher, making it somewhat unclear as to why your claim was rejected. Language may be vague or difficult to interpret. Yet it is vitally important to understand what the insurance company is telling you, in order to prepare for a winning appeal.
Common Reasons Long Term Disability Claims Get Denied or Terminated
Many people are late to file. They are going through a very difficult time and do not act right away on applying for their benefits. Maybe they are waiting to return to work and don’t think that they will need benefits. Or maybe they are just struggling to get their bearings and figure out what needs to be done. Regardless of the reason, the language of your insurance policy will spell out due dates for filing for benefits once you stop working. Filing on time is the low hanging fruit and all deadlines must be strictly observed.
On the topic of deadlines, please note that insurance policies governed by ERISA (a Federal Law) typically provide 180 days in which to appeal, once your claim has been denied by the carrier. While this is not a reason for the initial denial, it is the most important deadline to be aware of because if you do not submit a timely appeal, you will be out of luck in most cases.
Insurance Policy Criteria for Disability is not met
- Not meeting policy criteria will often turn on not meeting your insurance policy’s definition of disability. The insurance company may define being disabled differently than you do or differently than your doctor does. This is why it is important not to rely on generic language from your doctor stating that you are disabled. When working in the context of a disability insurance policy, disability is a legal definition.
- The definition of disability can change over time, according to the terms of disability policies. Typically, this change comes at the 24 month mark. This is when most policies switch from requiring that you can’t work in your “own occupation” to being unable to work in “any occupation”.
Your disability insurance company claims to have ‘caught you’
Don’t think for a minute that your disability insurance company isn’t spying on you. If you or your doctor say that you are unable to do something that is keeping you from returning to work, they can and often do check up on those claims. The overwhelming majority of long term disability claimants want nothing more than to be able to return to their jobs. They are legitimately unable to perform their jobs at the moment. This does not stop insurance companies from trying to catch people who are lying about their abilities. An obvious and very extreme example would be for someone who claims to have difficulty walking to be caught training for the next Ironman. Much more common are instances where someone with chronic pain is having a particularly good day and is seen playing with their kids outside or doing light yardwork, which will be misconstrued as dishonesty. Insurance companies may send people out to observe you. They cannot look in on your private time at home but there is nothing to stop them from being outside. More often, disability insurance reps will see what they can find on social media.
Insufficient Medical Evidence
Insufficient Medical Evidence to back up a long term disability insurance claim can mean many different things. These are examples of insufficient medical evidence:
- The Insurance Company doesn’t have complete medical records.
- Your medical records don’t support a disability. The Insurance Company has complete medical records, but your records do not support the reasons that you’ve given for not being able to work. This is as determined by the insurance company. Often, they are just not specific enough. Sometimes, their hired guns will prepare a report disagreeing with your own doctor, based on a review of the medical records without having even met you.
- Your doctor does not support your claim.
- You are not seeing your doctor regularly. Depending on the nature of your disability, you may be expected to see your doctor(s) more frequently than you do. This is similar to not following your doctor’s recommendations.
- You aren’t following your doctor’s recommendations. A common example of this is failure to go for physical therapy. If the records from your M.D. say that you are being referred to a physical therapist, but there are no records to indicate that you have actually gone, this will work against you.
- You have failed to provide medical updates on your disability. This is an often cited reason for termination of benefits. Once you are approved for long or short term benefits, it does not mean that you’ve heard the last of the insurance company. You are required to return to work (and thus stop collecting LTD or STD benefits) once you are better and able to resume employment. This means that the insurance company is going to check in from time to time and require updated medical records which support the ongoing nature of your disability. These requests often come in once you are about to transition from “own occupation” to “any occupation”, and often will happen before then, too. It is very important not to ignore requests for updates.
Most insurance disability policies will exclude claims brought within one year after coverage began. It will often also exclude medical treatment obtained for your disability before you obtained the policy.
The Motivation behind Long Term Disability Claim Denials
Disability insurance companies really do not want to pay out on policies. They are for profit companies and it is the adjuster’s job to look for reasons to deny all but the most obvious claims (and even the obvious ones are often denied). It is nothing personal to them, this is what they are being paid for. This is why you should not accept ‘no’ for an answer when you know that you truly cannot work, and have your doctor’s support. The insurance company wants you to just give in at this point.
Remember, short and long term disability claims are governed by the terms of your insurance policy and in many cases, also by Federal Law under ERISA (The Employee Retirement Income Securities Act of 1974). This means that there are rules that have to be followed by both sides. It can be very complex but you should not let the insurance company take the upper hand.
What to do when your Long Term Disability Claim is Denied
- Be Proactive: Immediately note the date that you received it and look for deadlines in your denial letter, especially as related to the date that your appeal is due.
- Gather all of your Medical Records.
- Call our office at 630 250-8813 for a free review of your denial letter. If you are an Illinois resident, our attorney will analyze the denial letter for you at no cost. If you are not an Illinois resident, we will try to help you find the right lawyer in your state (ERISA appeals lawyers are not easy to find).
- Request a free copy of our book about how the appeals process works.