If you are unable to work due to injury or illness, you may file a long-term disability claim to try to obtain benefits. Unfortunately, many LTD claims are denied. A skilled disability attorney can evaluate your situation and help you determine why your long-term disability was denied. Call CJ Henry Law Firm, PLLC today for help.
When long-term disability policies are provided by employers, they are governed by the Employee Retirement Income Security Act (ERISA), which is a federal law. Under this law, claims administrators who work for an insurance company evaluate LTD applications and make determinations about who may receive benefits. Deserving claims are often denied.
Long-term disability applications are denied by claims administrators for a variety of reasons, sometimes legitimate and sometimes illegitimate. By understanding why your claim was denied, you can file a strong appeal and possible case in federal court, if necessary.
It’s important to have medical records that support your claim in order to win LTD benefits. You must have regular medical treatment with a primary care physician and appropriate specialists. If you suffer from a mental condition, such as bipolar disorder or depression, then you should see a mental health provider as well. Additionally, your doctor should be sending you for objective tests, such as x-rays, MRIs, and CT scans, when appropriate and necessary.
LTD claims are often denied due to insufficient medical evidence when the insurance company fails to obtain all of your medical records. You can ask your disability carrier to give you a list of all medical records they have in your file. If any records are missing, you should make sure your insurer requests additional dates or records from all providers.
You should request a doctor’s statement from your treating physician. This statement will be one of the most important factors in proving your disability to the insurance company. The forms from your insurance company may elicit responses from your physicians that support denial. Instead, have your doctor write a letter that details your impairments and how they limit your work duties. If your treating doctor refuses to write such a letter, find another doctor who will. There are doctors who frequently work with disability cases that can greatly benefit your claim with their knowledge of how to write an effective statement to the insurance company.
Before submitting a claim to your LTD insurance company, you should check your policy’s summary plan description for a definition of disability. Some plans allow you to make a successful claim if you are unable to carry out the duties of your “own occupation.” However, other policies define disability as being unable to carry out the duties of “any occupation.” Some policies swap from “own occupation” to “any occupation” after a period of time, usually 24 months.
Your policy may also have excluded conditions or pre-existing conditions that are not covered for a period of time. Those often include things like substance abuse or conditions with self-reported symptoms. Conditions based on subjective complaints, such as depression, fibromyalgia, and others, may be limited to 24 months or less of benefits.
Your LTD insurance company may ask a medical expert to review your records or examine you independently. Doctors may complete an Independent Medical Examination (IME) or Functional Capacity Evaluation (FCE) to evaluate the impact of your disability on your work. If your treating physician and the insurance company’s experts have conflicting opinions, then your claim may be denied.
The LTD insurance company may ask an investigator to follow you and take video surveillance. If you are recorded doing things that you have claimed you are unable to do, then your claim may be denied or terminated.
Sometimes video surveillance will show you on a good day, especially if you have a condition like fibromyalgia where the pain may vary from day to day. Unfortunately, your claim may be denied or terminated based on that surveillance that catches you when you’re able to do things you’ve reported as being unable to do.
In order to avoid complications with investigators, you should always comply with your doctor’s restrictions. If a doctor advises you to walk with a cane, you should use it at all times, even if you’re having a “good day.”
When filing and appealing your claim, you will have deadlines that must be met. If your LTD insurance policy is governed by ERISA, then you will have 180 days to appeal an initial denial. If you miss these deadlines, then your claim may be permanently denied and you will be unable to file a lawsuit in federal court because you didn’t exhaust your administrative appeals.