Denied Long-Term Disability Coverage? What’s Next?

Have questions about long-term disability coverage? Contact disability attorney John Peace to schedule a free, fully confidential case consultation: (864) 298-0500.

Denied Long-Term Disability

Today, an increasing number of Americans face the denial of long-term disability coverage.

Unlike social security disability, your employer provides long-term disability coverage through an insurance company.

The coverage is governed by a federal law called the Employee Retirement Income Security Act (ERISA).

Insurance companies deny long-term disability applications for a number of reasons. If your insurance company denied your application, you have the right to appeal under ERISA. You can file a lawsuit against your insurance company if it denies your appeal.

This blog will offer guidance on what to do if you’ve been denied long-term disability insurance. We’ll also explain how to appeal your long-term disability denial and offer tips for improving your claim.

If you have been denied long-term disability coverage, you should talk to an ERISA disability attorney today.

A disability attorney can help you navigate the complex process of overturning disability insurance coverage denials.

Why Might an Insurance Company Deny My Long-Term Disability Application?

Unfortunately, there are many reasons insurance companies deny long-term disability applications.

Disability insurance policies are complicated contracts. In most cases, coverage comes with numerous limitations, exclusions, and conditions for receiving benefits. The complexity of the long-term disability claim process also gives insurance companies a lot of discretion in denying benefits. 

Let’s take a look at some common reasons that employees are denied long-term disability insurance coverage.

Insufficient Medical Evidence

Insufficient medical evidence is a common reason for long-term disability insurance denial. An insurance company is unlikely to approve your claim unless it has documented medical proof of your disability.

Your inability to obtain sufficient medical evidence often arises from a failure to get regular medical treatment. No matter what kind of condition you have, insurance companies want to see that you are regularly seeing medical professionals.

Medical professionals include your primary care physician and any appropriate medical specialists. For example, if your disability arises from a mental condition, you should be seeing a psychologist regularly.

Additionally, your claim might be denied for insufficient medical evidence because you don’t have a statement from your doctor saying that you have the disability you claim. Your doctor should provide you with a detailed opinion of your medical limitations and how they relate to your job.

This is all the more crucial if you suffer from a disability with symptoms that are self-reported, such as a chronic pain condition. Insurance companies are more likely to deny coverage for a disability based only on your subjective complaints. Having clear, objective documentation from a medical professional to back up your claim is essential.   

Inability to Meet Your Policy’s Definition of Disability

Often, insurance companies deny people long-term disability coverage because they don't meet their policy’s definition of disability.

Some insurance policies use an “own occupation” definition of disability while others use an “any occupation” definition. An “own occupation” definition means you are disabled if you cannot carry out the duties of your particular job.

However, an “any occupation” definition means you are disabled if you cannot perform the duties of any job. Whether your policy uses an “any occupation” or “own occupation” definition can have a significant impact on your case.

It is also important to understand that some conditions might not qualify under your policy’s definition of disability. Long-term disability policies often don’t cover medical conditions linked to substance abuse, self-inflicted injuries, or crime-related injuries. For example, consider someone unable to work due to complications from liver cirrhosis caused by alcohol abuse. An insurance company would likely deny their claim because their condition is the result of substance abuse.

A disability attorney can help you decide if your disability meets your policy’s definition.

Inconsistent Evidence from Video Surveillance

Insurance companies will go to great lengths to find reasons to disprove your disability claim. This can include investigation techniques that seem creepy or even invasive. Sometimes, investigators from insurance companies will follow and videotape you to confirm that you have the disability you claim. If investigators see you doing things that are inconsistent with the disability you say you have, they might deny your claim.

As a result, it is important to follow your doctor’s instructions regarding activities you should and should not perform. For example, you shouldn’t shovel snow if you’re not supposed to lift heavy objects.

Pre-Existing Conditions

Insurance companies generally refuse to grant benefits to employees whose disabilities are caused by pre-existing health conditions. Common pre-existing conditions that can lead to a denied claim include: 

  • Arthritis,
  • Heart disease,
  • Chronic high blood pressure,
  • Asthma,
  • Migraines, 
  • Epilepsy,
  • Diabetes,
  • Cancer,
  • HIV/AIDS, and
  • Crohn’s Disease.

If you suffer from one of these conditions when you sign up for coverage, you may be disqualified from certain benefits. Existing injuries or certain elective surgeries can also be grounds for a denial.

Insurers may use different criteria to define a pre-existing condition. Some policies might say you have a pre-existing condition if you had symptoms or sought professional treatment up to three months before your coverage started. Other policies might count conditions that arose during the past year.

Missed Deadlines

Tardiness can make or break your chances of getting financial assistance when you’re unable to work. It doesn’t matter how severe the state of your health is—insurers expect you to meet all required deadlines at each stage of submitting your claim. This can include deadlines for:

  • Notifying an insurer of your inability to work,
  • Providing proof of your disability,
  • Filing documentation that supports your claim,
  • Responding to follow-up questions, and
  • Sharing relevant medical updates.

Some missed deadlines may seem trivial. Unfortunately, an insurance company may use them as an excuse to deny you the coverage you deserve. 

Provider Error

Insurance providers aren’t infallible. Disability claims involve complex documentation passed between multiple claim representatives, some of whom may have less experience than others. Miscommunications and mistakes are possible at any stage in the claim review process. If your claim is rejected, it’s critical to request an in-depth explanation. 

Wrongfully Denied Long-Term Disability Coverage?

If you were denied long-term disability coverage, you can still appeal your denial. Hiring a qualified attorney can improve your chances of your denial getting overturned. Contact Peace Law Firm for a free consultation today.

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2018-07-10

How Do I Appeal My Denial of Long-Term Disability Coverage?

Under ERISA, employees who receive employer-provided insurance benefits can challenge denied claims through an administrative appeal process. ERISA  regulates the appeal process for long-term disability claims. However, each insurer may have its own specific procedure and documentation requirements. In addition to reading the information below, you should also check your denial letter to see whether it describes the appeal process.

Timelines

Under ERISA, you have 180 days from the date of your denial letter to file an administrative appeal. You file your appeal with the plan administrator.

The plan administrator then has 45 days from the date of your appeal submission to respond with a decision.

Writing Your Long Term Disability Appeal Letter

Your appeal letter needs to address every reason for denial of your long-term disability coverage stated in your denial letter.

Additionally, your letter should include information that you didn’t include in your initial disability application.

Specifically, your appeal letter should include:

  • The reasons your insurance company denied your application for long-term disability coverage;
  • Policy language that supports your disability claim;
  • Specific reasons why you believe your insurance company should cover your disability claim;
  • A discussion of your medical condition and why it prevents you from working;
  • Reference to supporting evidence, including case law;
  • Any new or updated medical records that support your claim; and
  • Contact information for you, your doctor, and any other relevant individual.

To make sure that your appeal letter is written as well as possible, you should consult a disability attorney.

An attorney can write your letter and make sure it includes all the necessary information and evidence.

Contents of Your Appeal

A detailed appeal letter doesn’t stand on its own. You also need compelling, detailed evidence to back up the claims you make in your letter.

Examples of supporting evidence include:

  • Medical, financial, and employment records;
  • Your claim file, including your doctor’s opinion on your medical limitations;
  • Correspondence between you and your insurance company; and
  • Third-party reports from friends, coworkers, and family members about your disability and how it affects your ability to work.

Include as much evidence as possible to support each reason for overturning your denial of disability coverage stated in your appeal letter.

Tips for Avoiding Denied Long-Term Disability Insurance Claims

Whether you are preparing an initial disability claim or an appeal, here are some guidelines that can help improve your case for receiving benefits. 

  • Understand your policy requirements. Review the details of your disability policy, including any limitations and exclusions that could impact your claim. For example, some plans require claimants to be working full time when they suffer their debilitating injury or illness. 
  • Keep detailed and accurate medical records. Seek regular treatment for your condition and stay in close communication with any physicians who treat you. Make sure they take note of all of your symptoms and the specific impact the symptoms have on your ability to work. 
  • Have your doctor write a letter. Instead of using the form provided by your insurance company, have your physician present their medical opinion in the form of a letter. The letter allows for more comprehensive details about your condition, boosts the credibility of your claim, and increases your chances of approval.
  • Confirm documents were received. Follow up with your insurer to ensure they receive all documentation and medical records supporting your claim. Arrange for tracking and delivery confirmation for anything you send by mail. 
  • Protect privacy online. Insurance investigators often turn to the digital world to evaluate the extent of your disability, so put your social media accounts in private mode to avoid scrutiny from investigators. Images—even old ones—of you doing activities a disabled person shouldn’t be able to could be used as evidence to deny your claim.
  • Get professional help. Long-term disability policies are complex contracts that most employees struggle to fully comprehend. An attorney experienced with ERISA claims can help clarify the details of your coverage and the eligibility of your claim.

Having the support of a legal professional can be valuable at every step of the disability claim or appeal process. An attorney can help work with your doctor to get the necessary medical records, help organize evidence, and draft a compelling appeal letter.

Why Should I Contact a Disability Lawyer?

Contacting a disability lawyer can help improve the chances that your long-term disability coverage denial will be overturned. 

The process of overturning the denial of your long-term disability coverage is complicated. A disability lawyer can help you avoid making mistakes that lead to further denials, such as including inaccurate or misleading information. Additionally, working with a disability lawyer can give you leverage against your insurance company.

If your insurance company denies your appeal, the next step in the process is an ERISA lawsuit. The success of an ERISA lawsuit depends on the quality of the information contained in your appeal because you cannot submit any new information.

A disability lawyer can make sure that you submit the best quality appeal possible.

Contact Us for Help with Denied Long-Term Disability Coverage

John Peace at the Peace Law Firm has been fighting insurance companies on behalf of disabled individuals since 2002.

John can help you:

  • Gather all the supporting information needed for your appeal;
  • Draft your appeal letter;
  • Include as much supporting documentation as possible; and
  • Ensure that your appeal is filed on time.

Contact us today to schedule your free consultation.

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