Why Do Insurance Companies Deny Legitimate Long-Term Disability Claims?
Insurance should make you feel safe—that’s its whole purpose. Long-term disability insurance can be a great safety net for employees by providing them with financial support when their health prevents them from working. However, the safety net doesn’t work if your provider denies your claim.
Many South Carolina residents with legitimate long-term disability claims might face disheartening denials. But why does this happen? There may be many reasons for a long-term disability denial, and not all of them are fair. At the Peace Law Firm, we can guide you through defeating a deni vnyal. Our team has over 20 years of experience and a strong focus on resolving benefit disputes. Contact us today for the skilled help of a seasoned benefits attorney.
Common Reasons for a Long-Term Disability Denial
Insurance companies are businesses; like any business, they aim to minimize payouts. While there are legitimate reasons for a denial, others employ tactics that can unfairly disadvantage claimants. Let’s review some of the common grounds for a denial.
1. Insufficient Evidence
To receive disability insurance benefits, you must provide written proof of your need for payment. Generally, the insurer must give you 90 days to submit proof and may require you to provide ongoing proof of your losses at reasonable intervals.
An insurance carrier might shut down your claim if you miss the deadline for submitting evidence or if it believes your evidence is unconvincing. But remember that late submission of proof is not a valid reason to deny a claim if your circumstances prevented you from submitting that proof by the deadline and you submitted it as soon as you reasonably could. Also, some insurers unfairly undermine the proof that claimants provide. The Peace Law Firm can review the evidence in your case to appeal any benefit denial you face.
2. Preexisting Disabilities
An insurance carrier might dismiss your claim by arguing that your disability was preexisting. South Carolina law allows long-term disability insurers to exclude coverage for preexisting disabilities, but their right to exclude depends on specific timing.
Insurers may exclude coverage for disabilities that begin in the first 12 months after a policy’s effective date, and an insurer might argue that your disability started earlier than it did to avoid paying. Thoroughly review your policy and healthcare records to ensure your insurer isn’t messing with timelines to support an unfair denial. You may also need a statement from a healthcare professional to prove your right to benefits.
3. Policy Lapses
A fundamental requirement for maintaining insurance coverage is the timely payment of premiums. Failing to pay premiums can cause your policy to lapse, resulting in a denial of any subsequent claims.
However, South Carolina law requires disability insurers to give a grace period to employers and employees to make premium payments before a plan lapses. Grace periods must meet the following minimums:
- Seven days or more for weekly premium policies,
- 10 days or more for monthly premium policies, and
- 31 days or more for all other policies.
Also, many insurers that provide indemnity for your hospital stays or benefits for the time you lose from work can’t deny benefits if a policy is discontinued while you’re in the hospital or out of work because of your disability.
Check the terms of your policy, policy notices, and premium deductions in each paycheck to help ensure you are up to date and covered. If your insurer claims a lapse, you may also need to speak to the benefits manager at your workplace to track your employer’s payment dates.
4. Claims of Intoxication or Illegal Activity
Many long-term disability policies contain exclusions for disabilities that result from the following:
- The insured being intoxicated or under the influence of narcotics, or
- The insured committing or attempting to commit a felony.
Determining whether an insured was attempting to commit a felony or was under the influence of a substance when they got hurt can be a fact-intensive task. There are also exclusions for narcotic use if you used them according to a physician’s advice. Speak to a knowledgeable attorney before accepting this type of denial. There may be several nuances in your case that uphold your right to coverage.
The Importance of Consulting a Lawyer When Long-Term Disability Is Denied
Navigating the complexities of a long-term disability denial can be overwhelming, especially when you are dealing with a serious illness or injury. If coverage for your long-term disability is denied, consulting with an experienced benefits lawyer as soon as possible may be crucial.
An attorney can help you do the following:
- Understand the terms of your policy by pinpointing your case’s most important policy provisions and help you use them to your advantage,
- Review the facts of your case and the denial letter to assess the legitimacy of a denial based on the policy terms and applicable laws,
- Help you gather the necessary medical and vocational evidence to strengthen your appeal,
- Draft a compelling appeal letter that can effectively articulate your case and legal arguments to the insurance company,
- Represent you in litigation by filing a civil lawsuit to fight for your benefits, and
- Protect your rights by ensuring the insurance company adheres to state and federal regulations.
Immediately contacting an attorney may be one of the best decisions you can make in your fight for long-term disability benefits.
The Peace Law Firm Is Here for You
At the Peace Law Firm, we are committed to helping South Carolina residents navigate the often challenging process of long-term disability claims. Attorney John Peace has been helping clients for decades and is a leader in the legal community.
If you have experienced a long-term disability denial, don't face the insurance company alone. Contact us today for a consultation to understand your rights and explore your options for appeal. We are here to advocate for you and help you secure the benefits you deserve.
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