What to do if your long-term disability claim is denied

If you have been diagnosed with a chronic condition that makes it difficult for you to continue working, you may rely on your long-term disability benefits to make ends meet. The question is what to do if your long-term disability claim is denied.

When you file a claim for long-term disability, the claim administrator for your case must determine whether there is sufficient evidence indicating that you suffer from a disability and truly deserve benefits. However, there are incidents where long-term disability claims have been denied, even when medical documents show that there is an actual case of disability.

The Employee Retirement Income Security Act gives you the right to appeal your denied claim. First, you may want to request your file from the insurance company. This shows all of the evidence, such as doctors’ files, memos, charts and reviews, the administrator used to make his or her decision to deny the case.

Now you can check for any incomplete information or miscommunication that may have occurred in your files. You can also get detailed medical letters from your physicians indicating your chronic condition and how it acts as a disability in your life. You can also include notes from your employer and people in your life who witness your struggle on a daily basis.

Once you have sufficient information, you can file an appeal. This process can take some time; however, there are ways you can speed up the process. In some cases, the insurance company may offer mediation or arbitration where you and an attorney can meet with officials to discuss the details of the case.

Specific Reasons Why a Long-Term Disability Claim May Be Denied

Insurers deny coverage for a variety of reasons. Some of the most common of them include:

• Failure to provide timely claim notification and documentation. Insurers expect you to provide immediate notice of your disability and timely follow-up. Claim handlers can deny claims if policyholders fail to comply with their requests within their designated timeframes. Timeliness is relevant at every step in the claim-filing process. A disability claim lawyer can help you keep on track and meet important deadlines.
• Insufficient claim documentation. Insurers make their decisions about claims based on the written proof of claimants’ disabilities. To get your claim approved, you’ll need to provide enough information to determine your long-term disability status. That could include medical records, pharmacy prescriptions, test results, chart notes, and physicians’ narrative reports. The burden is on you to provide proper documentation.
• Conditions that aren’t covered. Not all disabilities are covered under long-term disability plans. Exclusions identify circumstances or events that an insurance policy does not cover. Depending on the policy, exclusions may include injuries resulting from war, self-inflicted injuries, or disabilities related to the commission of a crime.
• Pre-existing conditions. Most insurers won’t pay out benefits for disabilities that are related to or contributed to by pre-existing conditions. If you experienced symptoms, took prescribed medications, sought treatment, or consulted a professional before the date your insurance went into effect, the condition for which you were seeking care may not be covered.
• Failure to meet disability guidelines. Social Security has its own definition of what makes a condition disabling, but there aren’t any uniform definitions for disability or total disability in private insurance, so each insurer defines these terms in their own way. You can reference your policy’s definitions section to determine whether you meet your insurer’s unique guidelines.
• Disputation of disability. When insurers have doubts about the extent of a claimant’s disability or the length of time it is expected to last, they sometimes require people to visit non-treating physicians for independent medical exams. If you’ve had an independent medical exam requested, you should seek legal counsel before you attend. These exams are often biased, and you can benefit from working with a lawyer.
• Lack of objective testing. Some disabling conditions, such as migraines or fibromyalgia, don’t show up on objective medical tests. You may need to submit additional convincing documentation to support your claim if your disability is subjectively determined.
• Adverse information. Your life could be opened up to intense scrutiny during an insurance investigation, which could lead to the uncovering of adverse information. If you’re caught performing activities that you claimed you could not perform, it could lead the insurer to question your disability status.
• Social media. Many people are caught engaging in activities that they claim they cannot perform on social media. This information can prompt insurance companies to deny disability claims. Setting your profile and all of your information to private can help to prevent this issue from coming up.
• Insurer error. Insurers may be forced to accept or deny claims under strict timeframes, which can lead to accidental errors or making a decision before all of the relevant information is available.

If your claim has been denied, you should file an appeal as soon as possible. For Employee Retirement Income Security Act-governed group disability claims, you must file within a certain time period. Many commercial insurers follow the same standards.

When to Hire a Lawyer

You can work with a lawyer to file your initial long-term disability claim. However, you don’t have to have legal counsel from the beginning to benefit from hiring a long-term disability lawyer. If your claim has been denied, you should hire an attorney right away to help you with your appeal.

Your attorney can help you with all aspects of the appeal-filing process, from gathering paperwork that proves you meet the definition of a disabled person to keeping track of deadlines and understanding disability laws and how they could impact your claim. Having a lawyer on your side can help to reduce your stress during this difficult time as you adjust to moving forward with a different kind of lifestyle.

FAQs

How Often Are Long-Term Disability Claims Denied?

Long-term disability claims are denied frequently. The award rate for disability insurance through the Social Security Administration in 2021 was just 26.8%, with many claims denied for technicalities rather than medical reasons. The situation is similar in the private insurance industry. If your long-term disability claim has been denied, you can work with a disability claim attorney to appeal the decision.

Why Do People Get Denied Long-Term Disability?

People get denied long-term disability for a variety of reasons. The most common one occurs when private insurers find insufficient medical evidence to prove that people’s conditions stop them from working full-time. Missing doctor notes, test results, or long gaps in treatment can make it more difficult to prove how severe the limitations on your life are. Failure to follow treatment plans can make it look like your condition has improved.

What Should I Do if My Long-Term Disability Is Denied?

If your long-term disability is denied, you should hire a disability claim lawyer to help you file an appeal. Your attorney can help you gather evidence to support your claim, file the paperwork correctly, and meet important deadlines so that you can prove the extent of your disability and won’t have the appeal rejected on a technical basis.

What Disqualifies You From Long-Term Disability?

Three things can disqualify you from long-term disability. Your claim could be denied if you don’t meet the specific medical, financial, or contractual terms outlined in your insurance policy. Issues such as preexisting conditions, insufficient medical evidence, and failure to meet the definition of disability can all come up. Technical problems like missed deadlines may also play a role.

Hire a Disability Claim Lawyer Today

If you’ve had your long-term disability claim denied, the first thing you should do is hire a disability claim lawyer to help you appeal the decision.

The law office of Jon Michael Smith is here to help, resolving disability claim disputes for more than 30 years. We work directly with you to find a resolution quickly, keeping you informed throughout the process and addressing any questions or concerns you may have promptly. Contact Jon Michael Smith to schedule an initial consultation regarding your disability case.

This information is intended to educate and should not be taken as legal advice.