Disability decision explained: In this article, we discuss the most common reasons cited by insurance companies as to why they are denying a long term disability claim:
Long term disability insurance companies oftentimes deny claims on the grounds that they say there is insufficient evidence or objective medical finding to support the claim. For example, in a case involving back pain, if there is an x-ray, then perhaps a better piece of evidence would be an MRI or a CT scan. In a mental health claim, if there are cognitive deficits or difficulty thinking and processing information, then a good piece of evidence may be neuropsychological testing. This is the type of evidence that an insurance company is looking for in evaluating a case.
There may be clerical or procedural errors in the claim. For example, the claimant, their doctor, or their employer maybe didn’t fill out a form that was necessary to process the case. Another procedural error is that the claim wasn’t brought in time, meaning that in most cases you have a specific time limit within which to bring your long term disability case to the insurance company’s attention.
Long term disability insurance companies deny claims is based on surveillance video that they’ve taken of you or the claimant. What that means is oftentimes the insurance company will hire a private investigator to conduct surveillance and record the claimant in their daily activities, and if there is evidence that the claimant is engaged in an activity that seems to contradict what’s in the medical records, then that can be used as a basis for a denial.
There may be policy exclusions for certain illnesses or injuries. For example, let’s say that the injury that leads to the disability that is the basis for the claim is a result of a self-inflicted wound. Some long term disability policies will not cover a self-inflicted injury. Or, let’s say that the injury was incurred during criminal activity. A lot of policies will say that you cannot receive coverage for an injury that you received while engaged in criminal activity, so that could be another basis for the denial.
This is a common one: insurance companies often deny claims based on a pre-existing medical condition. A pre-existing medical exclusion will oftentimes apply if the employee just recently started working for the employer. In most instances, if your disability begins within one year of employment and you receive treatment for that same condition within three months prior to your employment, then you may not have coverage due to a pre-existing condition.
There may be contradictory online evidence in your case. Social media is a big one. Oftentimes, the insurance companies will go to your Facebook profile, download pictures and videos that you posted, and if they show you engaged in certain activities, then they may try to use that type of evidence against you in your case.
If there’s just wrong or directly inaccurate information that’s put on a form, or let’s say that the form from a doctor was manipulated, then that can be the basis for denial due to fraud or misrepresentation.
Lack of Treatment
Oftentimes, claims are denied because the patient or the claimant is not getting enough treatment, or they’re not following prescribed treatment by their doctor. For example, if the doctor is prescribing a certain treatment that may improve the claimant’s medical condition and improve it to the point where they may even be able to return to work, but the claimant’s not undergoing that treatment, then that can be a basis for denial due to noncompliance.
The claimant must meet all the eligibility requirements under the policy to have coverage, and some of those requirements may be non-medical in nature. For example, most policies require the employee to have worked a certain number of hours or worked a certain number of days before they’re eligible for long term disability coverage, and I’ve seen denials where the insurance company is claiming that the claimant didn’t work a sufficient number of days or hours to have coverage under the policy.
Definition of Disability
You must always look at the actual definition of the term disability under the policy. Each policy specifically defines how they evaluate the term disability, so for example, under most policies, you’re disabled if you cannot perform all or substantially all of the material duties of your occupation, but you must look at the definition under your individual policy. Another part of the definition is that it oftentimes changes over time, such that after two years it’s not just whether you can do your job. It’s whether you can do other occupations, as well, so you must always be aware of how the definition of the term disability is defined in your policy.
Legal Representation in Long Term Disability Insurance Claims
Although based in Florida, the Ortiz Law Firm represents claimants across the United States. If your LTD claim has been wrongfully denied, delayed, or terminated and you’d like to speak to an experienced Pensacola Long Term Disability Insurance Attorneys contact us at (866) 853-4512 to schedule a consultation. We can help you evaluate your claim to determine if you will be able to access Long Term Disability Benefits and how to move forward with the process.