Common Reasons for Denial of Long Term Disability Claims
Posted on Fri, Dec 30, 2011 @ 10:58 AM
While a lawyer with Bemis, Roach & Reed, I've represented clients in their battles to access their Long Term Disability benefits and seen several reasons used to deny claims. Knowing the common reasons for denial before you've filed a claim can help you avoid potential road blocks to receiving your benefits.
Pre-existing condition – Like health insurance, Long Term Disability (LTD) insurance often contains exclusions for pre-existing conditions, or conditions for which you received treatment three to six months prior to your claim. These exclusions can last up to 24 months.
Lack of objective medical findings – Your doctor’s opinion that you are disabled must be supported by medical evidence (office notes, imaging studies, blood tests, etc.) and must not be inconsistent with substantial medical evidence in your administrative record. If there have been no lab tests, x-rays or other objective medical documentation to support an opinion of disability, your claim is more likely to be denied.
Can still perform your job – The inability to perform your own job is not the typical standard used. Most insurers look to how your “occupation” is performed in the national economy. This gives them plenty of leeway to argue that, even though you may not be able to perform your regular job, you can still perform your “occupation”.
Self-reported symptoms (migraines / fatigue) – Your claim has a higher likelihood of being denied if the condition by which you are disabled, such as migraines or fibromyalgia, relies heavily on subjective evidence like self-reported pain or fatigue. Typically, there are no lab tests or x-rays that will verify these conditions, so the task of proving your disability becomes much more difficult, though not impossible.
Not pursuing proper medical care / treatment – In order to be able to provide objective medical evidence for your administrative record (on which your claim is based), you must seek appropriate medical care. Without such care and the findings it generates, the claim reviewer has no way to verify your claim.
Failure to meet definition of disability – Your LTD policy includes a definition of “disability.” These definitions vary considerably from policy to policy. It’s entirely possible your condition satisfies the definition under one policy, but not under another.
Engaging in an act listed as a policy exclusion – Disabilities resulting from acts such as commissions of crimes or self-harm, like a suicide attempt or substance abuse, are often included in a LTD policy’s list of exclusions. Any claim based on actions on this list will be denied.
Failure to meet contractual eligibility requirements – Contractual eligibility requirements in your LTD policy typically include things like a minimum period of employment at the company that offered the policy before becoming eligible for benefits. If you don’t satisfy these requirements, your claim will be denied.
Misrepresentation on insurance application – Intentionally providing incorrect information on your policy application, which often includes questions about your health and medical history, will frequently result in a denial of your claim and your policy being terminated.
Capriciousness of LTD insurance provider – Even avoiding all of these claim pitfalls, your LTD insurance provider might deny your legitimate claim. This is because most LTD insurers decide your claim while under a conflict of interest. If they decide you deserve benefits, they must pay them out of their own pocket. It’s not surprising, therefore, that these companies often err on the side of denying. If you have been denied, contact us. We have been able to help hundreds of clients overturn wrongful denials.