Is Your Long-Term Disability Claim at Risk? Common Denial Reasons & How Dorian Law Can Help
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Are you facing the daunting prospect of filing a long-term disability (LTD) claim? Or worse, has your claim already been denied? You're not alone. The process can be confusing and frustrating, and insurance companies often deny legitimate claims. At Dorian Law, we understand the stress and uncertainty you're experiencing. We're here to help you navigate the complexities of LTD claims and fight for the benefits you deserve. Call us today to get help with a denied claim. We can help get your claim approved.
This blog post will break down the most common reasons for long-term disability claim denials in plain English, explain the crucial differences between ERISA and non-ERISA plans, and empower you with the knowledge you need to protect your rights.
Why Are Long-Term Disability Claims Denied So Often?
Insurance companies are businesses. Their primary goal is to protect their bottom line, and unfortunately, that can sometimes mean denying valid claims. While not every denial is malicious, understanding the common reasons for rejection can significantly increase your chances of success.
Top Reasons for Long-Term Disability Claim Denials:
Here are some of the most frequent reasons insurance companies use to deny LTD claims:
Insufficient Medical Evidence:
The Problem: This is arguably the most common reason for denial. The insurance company needs objective medical evidence to support your claim that you are unable to perform the duties of your occupation (or, in some policies, any occupation). This goes beyond a simple doctor's note saying you're "disabled."
What They Need: They want detailed medical records, including:
Doctor's notes: Consistent, detailed notes from all your treating providers (doctors, therapists, specialists) documenting your symptoms, limitations, diagnoses, treatment plans, and prognoses.
Diagnostic test results: Objective evidence like X-rays, MRIs, CT scans, blood tests, nerve conduction studies, etc., that support your diagnosis.
Functional Capacity Evaluations (FCEs): These are assessments performed by physical or occupational therapists that objectively measure your physical abilities and limitations. They are extremely important in many LTD claims.
Neuropsychological testing: If your disability is related to a cognitive impairment (e.g., traumatic brain injury, dementia, severe depression), neuropsychological testing provides objective evidence of your cognitive deficits.
The Key: Your medical records must clearly and consistently document how your medical condition prevents you from performing the essential functions of your job. Vague statements are not enough.
Failure to Meet the Policy's Definition of "Disability":
The Problem: Every LTD policy has a specific definition of what it means to be "disabled." This definition is critical. You must meet this definition to qualify for benefits.
"Own Occupation" vs. "Any Occupation":
Own Occupation: This type of policy requires you to be unable to perform the duties of your specific occupation. This is generally more favorable to the claimant.
Any Occupation: This type of policy requires you to be unable to perform the duties of any occupation for which you are reasonably suited by education, training, or experience. This is a much stricter standard.
The Shift: Many policies start as "own occupation" for a period (e.g., 24 months) and then switch to "any occupation." This is a common point of denial.
The Key: Read your policy carefully. Understand the exact definition of disability and make sure your medical evidence directly addresses that definition. Dorian Law can review your policy free of charge.
Pre-Existing Condition Limitations:
The Problem: Most LTD policies have a "pre-existing condition" clause. This means they may not cover disabilities that are caused by a medical condition you had before your coverage began.
The Look-Back Period: Policies typically have a "look-back period" (e.g., 3-12 months before the policy's effective date). If you received treatment or had symptoms related to your disabling condition during this period, the insurance company may deny your claim.
The Key: Be honest and upfront about your medical history when applying for coverage. If your claim is denied based on a pre-existing condition, an attorney can help you determine if the denial was justified.
Policy Exclusions and Limitations:
The Problem: LTD policies often contain specific exclusions and limitations. These can include:
Mental/Nervous Limitations: Many policies limit benefits for disabilities primarily based on mental health conditions (e.g., depression, anxiety) to a shorter period (e.g., 24 months).
Substance Abuse Limitations: Disabilities caused by or related to substance abuse may be excluded or limited.
Self-Reported Symptoms: Policies may be skeptical of disabilities based primarily on subjective complaints (e.g., pain, fatigue) without sufficient objective medical evidence.
The Key: Thoroughly review your policy for any exclusions or limitations that might apply to your situation.
Surveillance and Independent Medical Examinations (IMEs):
The Problem: Insurance companies often use surveillance (private investigators) and IMEs (exams by doctors hired by the insurance company) to gather information about your claim.
Surveillance: Investigators may video record you to see if your activities are inconsistent with your claimed limitations.
IMEs: IME doctors are often biased towards the insurance company. Their reports can be used to deny or terminate your benefits.
The Key: Be aware that you may be under surveillance. Be honest and consistent in your statements and actions. If you are required to attend an IME, an attorney can help you prepare and protect your rights.
Missed Deadlines and Procedural Errors:
The Problem: LTD claims have strict deadlines for filing the initial claim and appealing a denial. Missing these deadlines can result in your claim being denied, even if it's otherwise valid.
The Key: Keep careful track of all deadlines. An attorney can help you ensure that all paperwork is filed correctly and on time.
ERISA vs. Non-ERISA: A Crucial Difference
The type of LTD policy you have significantly impacts your rights and the appeals process. There are two main categories:
ERISA Plans (Employer-Sponsored):
What it is: The Employee Retirement Income Security Act (ERISA) is a federal law that governs most employer-sponsored group disability plans.
How it affects denials: ERISA often makes it more difficult for claimants to win their cases.
Limited Discovery: You may have limited access to the insurance company's internal documents and claim files.
Deferential Standard of Review: If your case goes to court, the judge will often defer to the insurance company's decision unless it was "arbitrary and capricious" – a very high standard to meet.
No Jury Trial: ERISA cases are decided by a judge, not a jury.
Limited Remedies: You are generally limited to recovering the benefits you were denied, plus interest. You typically cannot recover damages for emotional distress, bad faith, or punitive damages.
Appeal is critical. You have to perfect the administrative record during the appeal, which may be your only chance to submit evidence to support your claim.
Non-ERISA Plans (Individually Purchased):
What it is: These are policies you purchase directly from an insurance company, not through your employer.
How it affects denials: Non-ERISA plans are generally governed by state law, which is often more favorable to claimants.
More Discovery: You have greater access to the insurance company's files.
De Novo Review: If your case goes to court, the judge will review the case "de novo," meaning they will make an independent decision based on the evidence, without deferring to the insurance company.
Jury Trial: You have the right to a jury trial.
Potential for Bad Faith Damages: If the insurance company acted in bad faith, you may be able to recover additional damages, including punitive damages.
Proactive Steps to Protect Your LTD Claim:
Read Your Policy Carefully: Understand the definition of disability, exclusions, limitations, and deadlines.
Document Everything: Keep detailed records of all medical appointments, treatments, medications, and communication with the insurance company.
Seek Consistent Medical Care: Follow your doctor's treatment plan and attend all scheduled appointments.
Be Honest and Consistent: Provide accurate information to your doctors and the insurance company.
Don't Give Up: If your claim is denied, you have the right to appeal.
What to Do If Your Claim is Denied: Contact Dorian Law Today
If your long-term disability claim has been denied, don't lose hope. The experienced attorneys at Dorian Law can help you:
Understand Your Policy: We'll review your policy and explain your rights.
Gather Evidence: We'll help you gather the necessary medical evidence to support your appeal.
Navigate the Appeals Process: We'll handle all communication with the insurance company and ensure that all deadlines are met.
File a Lawsuit (if necessary): If your appeal is denied, we're prepared to fight for your benefits in court.
ERISA Expertise: We have extensive experience handling ERISA claims and understand the unique challenges they present.
Don't face the insurance company alone. Contact Dorian Law today for a free consultation. We're committed to fighting for the benefits you deserve.
Disclaimer: The information provided here is for general knowledge and informational purposes only, and does not constitute legal advice. You should consult with a qualified lawyer for advice regarding your specific situation.