Long Term Disability (LTD) insurance companies are notorious for denying legitimate claims based on obscure disability definitions contained in the policy. There is no one legal definition of disability. Every insurance company, the Social Security Administration and the Veterans Administration all have different definitions.
Disability is Defined by the Insurance Contract
The definition of disability is explained in the insurance policy and will vary from company to company. Usually, it is something along the lines of “due to sickness or injury the employee is unable to perform the material and substantial duties of his or her own occupation.” However, most policies shift the definition to a more difficult any occupation standard after a period of time, usually after 24 months. The insurance company defines disability, interprets the terms in their definition and decides whether a claimant is disabled or not. The insurance company decides whether or not a claimant will receive benefits. This creates an inherent financial conflict of interest.
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Your Doctor Says You Are Disabled! Why Doesn’t it Matter to Them
Because the insurance company decides whether or not a claimant is disabled, they will use their own employees, either a Nurse or an in-house doctor, to review a claimant’s medical records. Many times, these in house consultants will have an opinion that is different than a claimant’s doctor. The insurance company will state that the claimant’s doctor’s opinion is not supported by the medical records. The Supreme Court has looked at this issue and decided that the “treating physician rule” used by the Social Security Administration, does not apply in LTD determinations. The treating physician rules says if a treating doctor says a claimant is disabled, that opinion is entitled to “great weight.” In private disability plans, the Supreme Court has held that a claimant’s doctor’s opinion that the claimant is disabled should be taken into account as a “factor” in the insurance company’s determination of disability but is not binding on the insurance companies determination.
Social Security Says You Are Disabled! Isn’t That Enough?
For a person under 50 years old, Social Security’s definition of disability is actually a tougher standard than an LTD definition because a claimant must be unable to work at any occupation available in the national economy. But because Social Security has slightly different rules for disability, the insurance company will ignore an award of benefits by Social Security by stating that the rules are different.
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But the Long Term Disability Insurance Company Helped Me Get Social Security Disability
The insurance company is more than happy to help a claimant to get Social Security benefits because it helps them financially. The insurance company contracts with another company that represents claimants before the Social Security Administration. The insurance company will reduce a claimant’s LTD monthly benefit by the amount that claimant receives from Social Security and will demand that the claimant “pay back” the insurance company the back benefits received from Social Security. For more information on how to fight back when your LTD benefits have been denied, download our free e-book Disability Insurance Policies-How to Unravel the Mystery or visit disabilitydenials.com.
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