By Peter Casciano, Esq.
Employer-provided long-term disability (LTD) policies are governed by a federal law known as ERISA, the Employee Retirement Income Security Act. Under ERISA, disability applications are evaluated by claims administrators usually working for your insurance company.
Claims administrators deny disability applications for an endless number of reasons. Understanding why claims are denied and working with an attorney experienced in this area of law will help you present the best case possible.
To help you be better prepared, below we’ve outlined five of the top reasons long-term disability claims get denied:
#1 – Failure to Provide Objective Evidence of Disability
Although most Long Term Disability policies to do not expressly require the submission of objective proof of your disability, many insurance carriers prefer to see this type of evidence. A claimant should always explore the possibility of obtaining objective evidenced like medical imaging, testing, or laboratory blood work that helps corroborate the claimed illness or injury. For those disabilities where objective evidence is difficult or impossible to obtain, it makes the opinion evidence from the treating physicians that much more critical.
#2 – Failure to Provide Carrier Forms
It is very common for carriers to bombard claimants with duplicative or irrelevant requests for information. While it may feel like the carrier is requiring you to jump through hoops, it is imperative that claimants comply as best as possible with the carrier’s demands. A refusal to supply neutral or irrelevant information is giving the carrier an easy reason to deny your claim. Also, it is important to look at each carrier form as the claimant’s opportunity to tell their story and highlight the symptoms and limitations that inhibit their ability to work. Consistency is critical when completing multiple versions of the same form over the life of a claim. The carrier will be comparing one to the other an looking for inconsistencies or contradictions.
#3 – Failure to Meet the Definition of Disability
Knowing the definition of disability applicable to your claim is critical to whether the claim is approved. Your policy may require that you prove your inability to do your previous occupation, while another policy may require that prove your inability to do all full time work. Some policies limit the amount of full time work they will consider based on a percentage of your pre-disability earnings, like 60%. One cannot properly evaluate the strength or weakness of disability claim without being familiar with all ins and outs of the definition of disability applicable to you.
#4 – Failure to Treat
The clinical records generated while your claim is pending are very important to your case. Make sure that you have recently seen doctors critical to your disabling condition. Following their recommendations and adhering to their prescribed treatment is required for a successful long term disability claim. Claimants must also participate in their own treatment especially during this critical time period by communicating with their physicians, providing details of the side effects of prescribed medications and making sure the doctor is aware of your ceasing work.
#5 – Failure to Satisfy the Pre-existing Condition Clause in your Policy
If you have not been covered by your long term disability policy for long enough (usually one year), a pre-existing condition clause may be triggered that allows the carrier to review clinical records prior to your employment or disability coverage. If the carrier can prove you treated for your disabling condition during this “lookback period,” your claim may be denied. Key questions are whether your policy contains a pre-existing condition clause, when it is triggered, and how far the lookback period lasts.
ERISA is a complicated law and many rules govern the disability application process—from strict deadlines to what evidence is allowed during the appeal. If you or someone you care about has been impacted by a disability, you can prepare a better case by keeping the aforementioned denials in mind. If you need assistance in preparing your case, don’t hesitate to contact me for a free consultation.
About Andalman & Flynn, P.C.
Andalman & Flynn, P.C. serves clients throughout Maryland and the District of Columbia, offering compassionate, quality service and winning representation across a broad range of legal areas. With a concentration on disability benefits law and family law, the firm focuses on cases that impact the rights of everyone, and they are there for clients when responsive legal help is most critical. For more information about Andalman & Flynn, please visit www.andalmanflynn.com, or call 301.563.6685.