Top 10 Reasons Your Long-Term Disability Claim Will Be Denied
American workers deserve compensation when their health threatens their ability to perform the important duties of their occupations, and their wellbeing. This is why many employers provide group long-term disability insurance as an employment benefit. To protect their profits, however, long-term disability insurance carriers have become increasingly aggressive about denying legitimate long-term disability claims.
Workers need to take greater care than ever filing strong, well-documented, comprehensive initial claims, to counteract insurance companies’ growing tendency to say no to a valid long-term group disability claim. Here are the Top 10 Reasons long-term group disability insurance companies deny valid claims. Avoid these denials at all costs with help from a top-rated long-term group disability insurance lawyer.
1. Insufficient Disability Claim Documentation
The cardinal rule of submitting a claim for group long-term disability benefits is to provide thorough and complete medical documentation of the medical condition that makes you unable to work at your occupation. Your medical records provide the backbone of your disability claim. If you fail to provide all of the pertinent, necessary objective and subjective medical records the long-term group disability insurer requires (either because you did not gather them or you did not receive the treatment necessary to generate them), then the carrier will certainly deny your claim.
2. Erroneous Claim Documentation
As mistakes go, perhaps the only sin worse than not providing enough medical documentation with your group long-term disability claim is providing incorrect or misleading documentation. Your medical records must accurately reflect your physical and mental condition. The treating doctor’s statement that your group long-term disability will require you to provide in support of your claim must reflect a sound and reasoned medical opinion about your condition. Basic errors in describing your condition, even if made innocently and in good faith, can doom your claim from the start. Make sure your treating doctors understand the physical and mental demands of your work so they can explain why you are restricted and limited.
3. Untimely Claim
Virtually all employer-provided long-term disability insurance plans are governed by a federal law known as the Employee Retirement Income Security Act, or ERISA for short. ERISA sets the basic parameters for the content and administration of long-term disability plans, including the timelines for filing and responding to long-term group disability insurance claims. In filing a claim for long-term group disability insurance benefits, you must meet the proof of loss timelines set forth in your plan. Missed deadlines give insurance companies a clear path to deny an otherwise valid claim. A missed appeal filing is a fatal mistake often impossible to overcome.
4. Not a Covered Condition
Your employer-provided long-term disability plan may exclude some health diagnoses as a pre-existing condition. That is why you must make sure, before you submit a claim, that you have evaluated the full nature and extent of your health condition and its symptoms, including when the problem was first treated, medications or when your symptoms began. Some conditions, for example, may involve multiple, equally possible diagnoses, or may cause a constellation of symptoms, most of which are covered, even if one or several are not. Knowing what your plan does and does not cover, and exercising precision about how your treating doctor describes your condition and its symptoms in your claim submission, can make the difference between a claim approval and a claim denial.
5. Independent Medical Exam Results
Many long-term group disability benefits providers will require that you undergo a so-called independent medical exam (IME) as a condition of approving your claim. An IME is a medical examination conducted by a doctor chosen and paid for by the long-term group disability provider to evaluate your claim. Another way of saying this is that an IME is a medical exam by a doctor who looks for reasons to disagree with your treating doctor’s diagnosis and the treatment you received for your disabling condition. Frequently these doctors lack the proper training or specialization to evaluate your disability or are provided sparce or incomplete medical information. If at all possible, speak with an experienced group disability lawyer before agreeing to and attending an IME. An experienced ERISA attorney will know what the IME doctors are looking for and can suggest protections for you both before, during the examination and what you do following an IME exam.
6. Failure to Meet Policy’s “Disability” Definition
For all of the rules and regulations established under ERISA, it contains no uniform definition for what “disabled” means in the context of seeking benefits under a long-term group disability insurance plan. Broadly speaking, plans typically define disability as a health or accident-related injury that prevents you from performing the important duties of your occupation. The details are of the utmost importance. Don’t be fooled by “the fine print.” Some plans go so far as to regard you as disabled only if you cannot perform the important duties of any occupation by which you have been trained, educated or suited. If you are not sure how your long-term group disability plan defines disabled, review your policy or group certificate with an experienced ERISA lawyer before filing your initial claim.
7. Disputed Severity of Condition
Many health conditions become disabling only when they reach a certain level of severity. Another reason a long-term disability insurance company may deny your claims is if it disagrees with the assessment of the severity of your condition. Disputes of this nature can become somewhat subjective—for instance, a condition for which the principal disabling symptom is pain. Self-reported claims such as migraines, chronic fatigue or fibromyalgia may have a limited disability benefit period as short as 9, 12, 18 or 24 months. That is why it is critical to document your claim thoroughly and accurately in your claim submission with help from a seasoned ERISA lawyer.
8. Insurer Investigation
Insurance companies do not make money by paying out claims blindly. Long-term group disability benefits can amount to significant payouts. To limit their financial exposure, insurers may send investigators to your home or community to investigate whether you are indeed as disabled as you claim. Investigators may surveil claimants and take video of them going about their everyday lives, looking for examples of a claimant engaging in physical activities inconsistent with their disability claims. The danger of this sort of evidence, of course, is that it can end up badly misinterpreted. Speak with an experienced group disability insurance lawyer about the dos and don’ts of public activities after submitting a claim. If you say you cannot sit, stand, lift or bend, count on your group disability insurance company to hire videographers to follow you for a minimum of three days in a row.
9. Social Media
Social media users have become notorious for depicting a glossy, “too-good-to-be-true” version of their lives on Instagram feeds and Facebook timelines. We all understand the desire to present a curated life to the world, but that can backfire when you have a long-term group disability claim pending. Increasingly, investigators will comb social media looking for evidence that they can take out-of-context to suggest that your claim is not legitimate. Try to stay off of social media, if possible, if you intend to file a long-term group disability claim. Any activity on Facebook, Linkedin, or Instagram where you travel, party, fly or engage in any action the carrier deems inconsistent with your restrictions and limitations will quickly result in a denial.
10. Insurer Error
Sometimes, long-term disability plan administrators simply make basic mistakes in processing your claim. Unfortunately, getting a carrier to admit a mistake, and unwinding its errors, can prove difficult and time-consuming. An experienced long-term group disability attorney can help.
If you have questions about filing or appealing a long-term disability claim, contact an experienced long-term group disability or ERISA lawyer to help you get started on the right path to payment today.