Employer-provided or self-purchased long-term disability (LTD) is one of those ideas that look great on paper, but many claimants would suggest it often falls short of its promises. Understanding why a long-term disability claim might be denied and addressing the issue before filing is critical to ensuring you get what your policy says the insurance company owes you.
Because medical claims insurance administrators can be difficult, having a lawyer that excels in long-term disability claims is vital to ensuring you get what you deserve.
Here are a few common reasons LTD insurance administrators will try to deny claims.
Denial Is Good for Business
Insurance companies exist for two reasons, regardless of their advertisements and spokespeople claims: To make money and avoid paying it. That creates an inherent conflict of interest with the administrator who benefits from denying your claim. While that person may do nothing unlawful, they will almost always strictly apply the policy.
Lack of Medical Evidence
Long-term disability insurance companies routinely deny claims for lack of medical evidence. Lack of evidence could be the company’s position even if you and your doctor provided enough evidence to make your case.
Make sure you and your physician go overboard in providing the LTD company with proof of your condition and the degree to which it exists. There is no such thing as too much evidence.
Another approach the long-term disability company might use is claiming that what you provide does not work with their system. Discuss this with your physician or medical team to ensure that anything you send can be downloaded and read by the LTD company’s administrative and claims teams.
You should also have an alternative to get them what they need in the format they say they need that information. That includes any copies of documents or reports. It is a good idea to follow the rule that you can never send them too much evidence of your situation.
Lack of a Second (or Third) Opinion
LTD insurers often require you to get more than one examination to prove your condition. Failure to do that can result in them not honoring the policy. If you fail an independent evaluation or refuse to get one, you may risk the company not honoring your policy.
Timeliness of Claims
The timing of a claim is critical, and a long-term disability company has policy rules about when different parts of the claim must be filed. Timing is particularly important if you are challenging a claim, as internal insurance appeals processes can be very deadline-driven. Miss one, and you could lose your appeal.
Condition Definitions
Your policy may contain fine print that provides these definitions:
- What qualifies as a disability
- What type of disabilities the company will cover
- Definitions of the disability and levels of conditions
- Requirements on your part to remain in good standing with the policy
Pre-Existing Conditions
If you had a condition before the policy was in effect, the insurance company might refuse to honor your disability compensation agreement. If the company claims you had a condition prior to the claim, you will have to prove that your current condition is why you are injured or sick.
The Meaning of Disability and Coverage
Some companies and lawyers will use very particular language in defining what a disability is and what coverage means. Sometimes, the term is defined so precisely that it is almost impossible to qualify. Make sure you read the fine print before getting the policy to understand how the company defines a disability and coverage, so you are not surprised.
Non-Adherence to the Policy
Insurance policies have stipulations you must meet to make the policy applicable. Stipulations can include requiring you to do certain things to prove your condition, ongoing treatment requirements, etc. One crucial requirement almost always is that you follow their physicians’ advice to the letter.
That can mean attending physical therapy, agreeing to follow-up visits, maintaining specific health regimens, etc. It also can mean that you must pursue other medical tests or procedures to maintain disability status. Keep in mind that the purpose of these clauses is not to help you recover but to limit the company’s liability.
Occupational Limits
Some long-term disability policies and lawyers have rules about what you can and cannot do as part of your occupational pursuits.
Some policies pay based on a condition that prevents you from performing your specific occupation, while others will make benefits contingent on being unable to perform duties related to “any occupation.” Specific occupational clauses often will have term limits for benefits.
Alleged Fraud
Some companies will hire investigators to follow you and document your activities. Several high-profile disability cases have made news headlines when disability recipients have been caught performing activities they said their condition prevented.
You should assume someone is watching what you are doing when claiming a disability or receiving compensation from one.
Legal Representation Can Help You
LTD insurance companies will often try to take advantage of those not backed up by a legal team. If you are claiming disability, you should contact a disability lawyer as soon as possible to ensure you get the help you need. After all, you or your employer paid for the contract, and you deserve to have it honored whether a disability insurance carrier wants to or not.
Contact Mottaz & Sisk Injury Law today to speak with our experienced legal team about your long-term disability claim.
