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Why Was Your Short-Term or Long-Term Disability Claim Denied?

California LTD Insurance Attorney

Countless workers have experienced the frustration of submitting a claim for short-term or long-term disability benefits through their employer-sponsored disability insurance plan, only to have their legitimate claims denied.

Group disability insurance is supposed to be there when injured or sick workers need it most. Being told “no” by an insurance company feels like a slap in the face that makes a bad situation—sudden disability and loss of income—even worse. For most, it is a devastating insult to the sickness or injury that takes an insured to their breaking point.

In this blog post, we examine some of the most common reasons short and long-term group disability insurance companies give for denying a valid claim for benefits. For answers to your questions about having a disability claim denied arbitrarily and in bad faith, contact an experienced group disability lawyer today.

Group Disability Insurers Look for Reasons to Say “No” to a Legitimate Claim

Employers provide short-term and long-term group disability coverage for employees as a benefit. The coverage is supposed to serve as a financial backstop for a worker who becomes disabled and cannot perform the important duties of their occupation, but still needs income to pay bills and manage day-to-day life. Group disability should give disabled workers peace of mind when the unthinkable occurs.

Unfortunately, group disability insurance does not always work that way. Insurance companies that issue short-term and long-term group disability coverage do not make money by paying every claim that comes along. Carriers stay in business, and make profits, by looking for any reason to delay and/or deny a valid claim. Reasons such as the following:

Insurance Does Not Cover Your Particular Disability

Some employer-provided, short-term and long-term disability insurance is highly regulated under a federal law known as the Employee Retirement Income Security Act (ERISA). You might think one of those aspects is what it means to be disabled and eligible for benefits.

Believe it or not, you’d be wrong.

Every short-term and long-term group disability insurance policy contains a definition of what it means for a worker to be disabled and eligible for benefits. A group disability insurance company can concerns about disclosing particular information if it determines that your disability doesn’t fit their criteria or eligibility rules.

For example, some policies call you disabled if you cannot perform the important duties of a specific occupation, while others only treat you as disabled if you cannot perform the important duties of any occupation by which you are trained, educated or suited.

Some short-term disability policies exclude specific health conditions such as mental health from coverage, while long-term disability policies may include the coverage but limit benefits to 12 months, others include them. Exclusion is not the end, however—the policy may exclude a specific disabling condition, but not a disabling symptom associated with that condition, or vice-versa. A top-rated disability lawyer can review your disability insurance policy to see if another covered injury, illness, or symptom might allow benefits.

Before concerns about disclosing particular information for short-term or concerns about disclosing particular information, familiarize yourself with what it means to be disabled under your employer-sponsored coverage—or better yet, consult a top-rated group disability lawyer. Sometimes, the difference between a claim approval and claim denial depends on how you and your treating doctor describe and document your disabling health condition. An experienced group disability lawyer can help you and your treating doctors present the proper medical and occupational evidence documenting the physical and mental demands of your work you are unable to do.

You Did Not Supply Sufficient Proof of Your Disability

Disability insurance companies do not approve claims without compelling medical evidence and proof of your disability. That usually means witness affidavits, accident reports, your treating physician’s chart notes and complete medical records and testing, pharmacy records, and your treating doctor’s detailed opinion on why you are unable to perform the important duties of your occupation, or in some cases, any occupation by which you are trained, educated or suited.

Some people balk at the idea of sharing their medical records with an insurance company. They understandably worry about privacy and divulging personal details about themselves. The fact is, however, obtaining short-term or long-term disability benefits require at least some disclosure of those private records. If you have concerns about disclosing particular information, speak with your doctor and an experienced disability attorney today to discuss which records you absolutely must provide to support a claim, and which (if any) you may protect.

You Missed a Deadline or Made a Mistake in Your Claim

It will probably come as no surprise to learn that virtually all group disability insurance policies have strict, unforgiving deadlines and procedures that you must follow. Missing a deadline can be fatal to your claim and lead to a loss of your legal rights. You must submit a timely, bullet-proof claim and meet all policy requirements.

Consult the Summary Plan Description provided to you by your employer to identify the deadlines applicable to your group disability claim. Better yet, speak with an experienced disability lawyer to learn more about filing deadlines and other pitfalls before making a fatal claim mistake on your ERISA claim.

The Insurance Company Investigated Your Claim and Did Not Like What it Found

Short-term and long-term disability insurance companies will sometimes investigate if they question the validity or truthfulness of a worker’s claim for benefits.

In this day and age, insurance companies conduct online investigations that examine a worker’s social media accounts. If they see a post that seems at odds with the disability claim, they might wrongfully deny the claim for that reason. Perhaps unsurprisingly, investigators misinterpret evidence they collect in their investigation, leading to a bad-faith claim denial.

The best way to avoid having a concerns about disclosing particular information is to tell the truth on applications, submit the proper and most persuasive evidence in your disability claim, and stay off of social media.

Also, keep in mind that insurance companies must not deny claims based on false information. If you believe you received a claim denial based on the insurer’s wrongful interpretation of the occupational, financial or medical evidence, speak with an experienced group disability lawyer right away.

Legal Help for a Denied ERISA Disability Claim

You do not have to take no for an answer from a group disability insurance company. Under policies covered by ERISA, you have the legal right to timely and comprehensively concerns about disclosing particular information with your insurance company.

For most people, filing a successful administrative group disability appeal means consulting a top-rated disability attorney. Disability insurers may try to make it seem easy and straightforward to appeal a denied claim, but the fact is, under ERISA, you have only one shot at getting an administrative appeal right. Whatever medical, occupational, financial or vocational evidence must be submitted with your administrative appeal because whatever you forget, didn’t include, or mistakely thought a lawyer could add later, is out. The record is closed as there is no discovery in an ERISA lawsuit, only the court deciding whether you are disabled or not on the administrative record.  ERISA severely restricts your ability to file a federal ERISA lawsuit to overturn the denial of your administrative appeal.

A skilled ERISA disability attorney can collect, organize, and present all of the occupational, financial and medical evidence and legal arguments you need to make to get the disability insurer to change its mind, or lay the groundwork for a federal ERISA lawsuit should the administrative appeal fail.

Don’t make fatal group disability claim mistakes, leaving yourself disabled and without benefits. If your disability insurance company denied your valid group disability claim, contact a top-rated disability attorney today to learn about your legal rights.

DarrasLaw is Americas' most honored and decorated disability litigation firm in the country. Mr. Darras has seen more, evaluated more, litigated more, and resolved more individual and group long term disability and long-term care cases than any other lawyer in the United States.

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