Long-term disability claims can be denied for many reasons, big or small. Even a missed deadline or error on your claim form can significantly impact your life. Unfortunately, denied disability claims are all too common.
If your insurer has denied your long-term disability claim, it’s important to understand why and determine what course of action to take. You should not delay, as the process to appeal the decision is subject to strict deadlines.
We highly recommend that you seek the support of a qualified long-term disability attorney to help guide you through the complicated appeal process. Now is not the time to try to become an expert in disability law on your own.
In this article, we’ll discuss five of the most common reasons long-term disability claims are denied and what to do if it happens to you. Remember that each insurance policy is different, and additional reasons may apply to your situation.
What we’ll cover:
- 5 common reasons long-term disability can be denied
- What to do if your long-term disability is denied
5 common reasons long-term disability can be denied
1. Insufficient medical evidence
To apply for long-term disability benefits, you must show that your medical condition or injury has prevented you from working. You must have the support of one or more treating physicians, or you will not be able to prove your claim.
Insurance companies often send attending physician’s statement forms to your treating physicians. Do not rely on the forms from your insurance company. They ask questions designed only to satisfy the minimum level of information necessary to fulfill the law and their judgment.
Contact your doctor and other medical professionals directly, and ask if they will write a statement on your behalf.
2. Failure to meet the definition of disability
Your insurance policy will have a specific definition of disability. To be eligible for benefits, you must meet this definition.
You must know how disability is defined in your long-term disability policy.
Under most policies, “disability” is defined as a person’s inability to perform duties under their regular job or “own occupation.” Some policies define disability more broadly to apply to “any occupation” you can do for a specific income. The definition of disability in your plan may change after a certain length of time, usually 24 months. Also, some disability insurance policies exclude coverage for pre-existing conditions.
You must know how disability is defined in your long-term disability policy. If you don’t already have one, request a copy of your policy from your plan administrator as soon as possible to understand the plan’s terms and limitations.
3. Inconsistent evidence to support disability
Your insurance carrier might deny or discontinue your disability benefits if your medical records, statements, and daily activities do not align. Even your social media posts can also be used to verify your claims.
For example, in the landmark case of Flaaen v Principal Life Insurance, Principal denied benefits based on an incorrect interpretation of a social media post. However, Roy Law Group successfully challenged this decision, and the court overturned the denial.
Follow your doctor’s instructions, and do not exaggerate your limitations to your insurance company. Your claim will be denied if they determine that you made false statements or provided fraudulent information.
4. Missed deadlines or errors in your claim
You must file your long-term disability claim right after your diagnosis — most policies require notification within 60 days. If you miss this deadline, the insurance company can deny your claim for lack of timely notice.
Before filing your claim, you should do your best to gather all medical records and any other supporting documentation. Submit your claim as soon as possible, even if you don’t have all the necessary documents, then keep your insurance company informed as you get additional details.
5. Conflicting medical assessments
Insurance companies may hire medical experts to determine your eligibility for long-term disability benefits.
They may even require you to have one or both of these tests to evaluate the impact of your disability:
- Independent Medical Examination (IME)
- Functional Capacity Evaluation (FCE)
These tests can be inaccurate or biased in favor of the insurance company, which may conflict with your doctor’s assessment. They often use the results to prove that you do not qualify as disabled. However, if you choose not to participate, the insurance company can deny your claim.
If your insurance company has requested that you participate in either of these examinations, you must talk to an attorney right away.
What to do if your long-term disability is denied
If you have been denied long-term disability benefits, you’re facing an uphill battle — but there is still hope. It’s important to take immediate action in order to appeal the decision and get the benefits you deserve.
Here’s what to do next if your long-term disability is denied:
1. Understand why the claim was denied
Carefully review your denial letter and your insurance policy to understand the reason for the denial. Pay attention to any deadlines for filing an appeal and the specific reasons for the denial.
Suppose the denial was based on a technicality, such as an incorrect or incomplete form or a lack of medical documentation. In that case, you should work to provide the necessary information and resubmit your claim.
2. Gather additional evidence
If you believe the insurance company’s decision was incorrect, gather additional evidence to support your claim. This may include medical records, letters from your doctor, and statements from coworkers or family members about how your disability affects your ability to work.
If your retirement plan falls under the guidelines of the Employee Retirement Income Security Act (ERISA), this will be the final chance to provide proof for your claim in your claim file. It’s better to include more evidence than necessary instead of not enough.
3. Consider hiring an attorney
The appeal process is incredibly complicated and difficult to navigate by design. If you’re struggling, we strongly recommend hiring an attorney specializing in long-term disability and ERISA. A qualified attorney can help you understand your legal rights and handle all of the complexities of filing a disability claim or appeal.
4. Draft an appeal letter
Write a detailed appeal letter that explains why you believe the insurance company’s decision was incorrect. Be sure to address any specific reasons for the denial and include any new evidence you have gathered.
5. File a long-term disability appeal
Submit your appeal letter and any additional evidence to the insurance company within the deadline specified in the denial letter. You should file an appeal only after you have gathered all relevant evidence.
It’s a good idea to keep copies of everything you submit for your own records and follow up with your insurance company to confirm they received it.
You are not alone
A long-term disability denial can have a devastating impact on your life. Dealing with a chronic injury or illness is difficult enough without the added stress of wondering how you’ll support yourself without disability insurance benefits.
Additionally, the appeal process is complex and has strict deadlines, especially for employer-sponsored plans governed by ERISA law. A simple mistake on your appeal could prevent you from receiving the benefits you deserve.
The good news is that you have the right to appeal a denied claim, and help is available.
At Roy Law Group, we have been handling long-term disability insurance cases exclusively since 2009. Our team of experts can handle everything for you, as this area of the law is incredibly complicated. If we take on your case, you can rest assured that you are in good hands and have a strong chance of winning your battle.
This article was first published on October 10, 2017, but has since been updated for accuracy and relevance.