Injured workers depend on disability benefits to make ends meet if they cannot work due to a serious medical condition. Employers in group plans often provide Long Term Disability (LTD) insurance, or individuals may buy their own. It is common for insurers to delay benefits to enhance their bottom line.
Contact Marc Whitehead & Associates for a free consultation. We take clients nationally and can help you understand why your claim was denied and file an appeal with a long term disability lawyer to advocate on your behalf. Call today for a free consultation.
Incomplete Documentation
When you file a claim for Long Term Disability benefits, you must provide proof of your medical condition. This includes all objective medical evidence that shows you are being treated for a disability. It could include:
- Diagnoses
- Medication prescriptions
- X–rays
- MRIs
- Lab results
If you have a mental disorder, you must provide proof that you are seeing a therapist or physician for your condition.
Always follow up with your care team to ensure your medical records are accurate and complete and have been sent. The insurance company can easily deny your claim without evidence to substantiate your medical condition.
For a free legal consultation, call 800-562-9830
Discrepancies and Omissions in Medical Records
Discrepancies in your medical reports are another common reason for denials. Your health records should be consistent regarding your diagnosis and how your condition affects your employment.
Omissions are just as problematic. Insurance companies typically send forms to your treating physicians with questions to satisfy the minimum amount of information required under the law. Don’t rely on these forms to prove your claim. Ask your physicians to write a more comprehensive statement on your behalf.
For example, two doctors are treating you. One is a primary care physician, and the other is a specialist. Ask them both to provide statements confirming that:
- you have a disability and
- that disability impacts your ability to work.
Your physicians should explain in detail how your condition directly prevents you from performing your job’s tasks. Without these details, it’s easier for insurance companies to question the validity of your claim.
Failure to Meet Policy Eligibility Criteria
Whether your employer provides LTD insurance coverage or you purchased it directly on your own, it is essential to read and understand the eligibility requirements outlined in your policy. Review these requirements to ensure you meet the criteria before submitting your claim.
Most policies exclude:
- Pre–existing conditions
- Work–related injuries
- Health problems related to drug use, alcohol use, and intentional acts.
Note that workers’ compensation insurance covers job-related injuries and illnesses.
Some insurers reduce or deny coverage for subjective complaints that are more challenging to document, such as depression and other mood disorders, chronic fatigue syndrome, and symptoms associated with healthy pregnancies.
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Pre-Existing Condition Exclusions
Pre-existing medical conditions are illnesses you have been diagnosed with or treated for within a certain period before applying for your policy. This is known as the “look back” period, which can range anywhere from 90 days to a year leading up to the time you acquired coverage.
It is possible to challenge a denial of benefits based on a pre-existing condition. Some federal courts have found that treatment for symptoms without a formal diagnosis is not grounds for denial based on a pre-existing condition exclusion.
An attorney for Long Term Disability claims may also argue that prior treatment was preventative rather than medically necessary for a specific, diagnosed condition. We can also challenge the criteria for pre-existing conditions altogether based on the terms of your policy and medical records. Our defense depends on the specifics of your individual case.
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Waiting Periods
Most disability insurance policies have a waiting period or elimination period ranging from 90 to 180 days. You must meet the criteria for Long Term Disability for this period before the insurance company starts paying out benefits. You can be denied benefits if you fail to qualify as disabled at any point during this waiting period.
With employer-provided benefits, waiting periods can vary based on the covered classes of workers. Again, a thorough understanding of your specific policy requirements is the first step to submitting a claim that is more likely to be approved.
Missing Deadlines
Meeting the required deadlines to file your initial claim and submit the proper paperwork is essential for a good outcome. Documentation submitted after these dates is unlikely to be considered part of the “administrative record” or considered evidence, regardless of how important it may be.
You have 180 days to file an appeal if your claim is denied. Once you miss that deadline, you generally forfeit the chance to sue your insurance provider in federal court. Know these critical deadlines, organize your documents, and act quickly to avoid jeopardizing your claim.
Surveillance
Insurance companies are known to employ surveillance tactics in an attempt to undermine disability claims. They may hire private investigators to monitor your daily activities and social media presence, looking for any evidence that contradicts the limitations you reported.
Even minor inconsistencies can provide grounds for a denial. Be very cautious when posting on social media.
Self Inflicted
Additionally, claims related to self–inflicted injuries or those resulting from the commission of illegal acts are commonly excluded from coverage under Long Term Disability policies. Insurers may argue that injuries sustained while driving under the influence or participating in criminal behavior should disqualify you from receiving benefits.
If faced with a denial for this reason, an experienced attorney can scrutinize the policy language and circumstances to determine if you have grounds to appeal.
Ultimately, having knowledgeable legal representation is invaluable when insurance companies employ underhanded tactics or make overly broad exclusions in an attempt to avoid paying out legitimate claims. A skilled Long Term Disability attorney can fight for your rightful benefits.
Marc Whitehead & Associates: Successfully Appealing Denied Claims for Over Three Decades
Long-term disability appeal assistance is available from Marc Whitehead & Associates. Since 1992, we have advocated for disabled clients nationwide, helping them overcome roadblocks to obtaining the benefits they are entitled to under the law.
We have a deep understanding of why claims are denied and have the skills and experience to build strong cases for appeals. We ensure your documentation is accurate, complete, and submitted on time.
Further, we work directly with your healthcare team to gather evidence to show the seriousness of your disability and that it keeps you from working.
Call to schedule a free consultation today. From our offices across Texas, we serve clients nationwide.
Call or text 800-562-9830 or complete a Free Case Evaluation form
