• Menu
  • Skip to right header navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer

Before Header

Has your disability claim been wrongfully denied or terminated? Call us today for help!  (888) 321-8131

  • Facebook
  • Instagram
  • LinkedIn
  • Twitter
  • YouTube

OLF Ortiz Law Firm National Disability Attorneys

We appeal wrongful long term disability insurance and Social Security Disability denials.

  • ABOUT US
    • Our Team
    • Our Results
    • Areas We Serve
    • Core Values
  • PRACTICE AREAS
    • Administrative Appeals
    • Lawsuits
    • Lump Sum Settlement Offers
  • RESOURCES
    • Top 10 Mistakes That Will Destroy Your LTD Claim
    • Physical RFC Form
    • Mental RFC Form
    • Ultimate Appeal Checklist
    • Long Term Disability Case Study
    • Lump Sum Disability Buyout Calculator
  • BLOG
    • Long Term Disability Denials and Appeals
    • Medical Eligibility for Long Term Disability Claims
    • Eligibility for Long Term Disability Claims
    • Your Chances of Getting Approved for Disability Benefits
    • Additional Parts Of A Claim That Do Not Happen in Every Case
  • Search
  • CONTACT
  • ABOUT US
    • Areas We Serve
    • Testimonials
    • Our Team
      • Nick Ortiz
    • Our Office
    • Core Values
    • Referring Attorney Program
  • PRACTICE AREAS
    • Long Term Disability Claims
      • Administrative Appeals
      • Lawsuits
      • Lump-Sum Buyout Offers
    • Social Security Disability Claims
      • Initial Applications
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • Cigna
    • Guardian
    • Hartford
    • Lincoln Financial
    • Matrix Absence Management
    • MetLife
    • Mutual of Omaha
    • Northwestern Mutual
    • New York Life
    • Principal
    • Prudential
    • Reliance Standard
    • Standard
    • Unum
  • RESOURCES
    • Blog
    • Free Downloads
    • Lump Sum Disability Buyout Calculator
    • FAQ: Long Term Disability
    • FAQ: Social Security Disability
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT

Mobile Menu

Schedule A Free Consultation Now!

Find out how our law firm can help you win your case or you don’t pay a cent.

(888) 321-8131

  • ABOUT US
    • Areas We Serve
    • Testimonials
    • Our Team
      • Nick Ortiz
    • Our Office
    • Core Values
    • Referring Attorney Program
  • PRACTICE AREAS
    • Long Term Disability Claims
      • Administrative Appeals
      • Lawsuits
      • Lump-Sum Buyout Offers
    • Social Security Disability Claims
      • Initial Applications
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • Cigna
    • Guardian
    • Hartford
    • Lincoln Financial
    • Matrix Absence Management
    • MetLife
    • Mutual of Omaha
    • Northwestern Mutual
    • New York Life
    • Principal
    • Prudential
    • Reliance Standard
    • Standard
    • Unum
  • RESOURCES
    • Blog
    • Free Downloads
    • Lump Sum Disability Buyout Calculator
    • FAQ: Long Term Disability
    • FAQ: Social Security Disability
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT
  • Facebook
  • LinkedIn
  • Twitter
  • YouTube
You are here: Home / Long Term Disability / Disability Decisions Explained

Disability Decisions Explained

July 14, 2020 //  by OLF//  Leave a Comment


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:

Insufficient Evidence

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.

Clerical Errors

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.

Surveillance

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.

Policy Exclusions

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.

Pre-Existing Conditions

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.

Social Media

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.

Inaccurate Information

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.

Non-Medical Requirements

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. 

FacebookTweetPinLinkedInPrintEmail

Category: Long Term Disability, Long Term Disability Denials and Appeals

Recent Posts

  • Marselle v. Unum – Kentucky District Court Finds Unum Made a “Reasoned Determination”
  • Foss v. Standard – “Own Occ” is With Any Employer, Not With Specific Employer
  • SSA Grid Rules Explained
  • What is a Trial Work Period? [2022 Update]
  • Can A Doctor Refuse To Fill Out Disability Forms?
Previous Post: « Long Term Disability Denied From the Beginning: Was Anything on Your Application Harmful to Your Claim?
Next Post: 10 Things You Need to Know About Long Term Disability »

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

Top Ten Mistakes That Will Destroy Your Long Term Disability Claim

View All Resources


Robby S.

When I was denied my second appeal for disability, I had to find an attorney to represent me. When I went online, I found dozens and dozens of attorneys that specialize in disability. So I read many reviews, and I selected Nick Ortiz. Selecting Nick Ortiz's firm was one of the best choices I have ever made. Nick Ortiz's law firm has an excellent staff. Sarah (one of the staff) has over 10 years of professional experience in the legal field, and she could answer my questions and put me at ease when I called. Tory, the paralegal assigned to my claim, has over 20 years experience. She was very empathetic to my situation and did a great job calming me down and gathering the records from the nine doctors I am seeing. Tory and Sarah were always accessible and patient no matter what questions I had. Nick is a no-nonsense man. My conversation with him put my mind at ease. They also have online courses called the Disability Academy that address everything you need to know before the hearing with the ALJ (the Administrative Law Judge). The veteran staff is there to answer all of your questions and treat you with compassion. I asked Nick what he thought my chances were, and he replied, "I have looked at your case, and I am in it to win." And win, he did. I received full disability. I would highly recommend Nick Ortiz to represent you! The firm provides everything to help you prepare for your hearing.

View All Testimonials

Complete this CONFIDENTIAL form or call (888) 321-8131 for a FREE case evaluation

  • This field is for validation purposes and should be left unchanged.

Practice Areas

  • Long Term Disability Insurance and ERISA Disability Insurance Claims
  • Social Security Disability Claims
  • Personal Injury Claims

Footer

Location

ORTIZ LAW FIRM
(888) 321-8131

316 S Baylen St
Ste 590
Pensacola, FL 32502
Monday - Thursday: 9:00 AM - 5:00 PM Friday: 9:00 AM - 2:00 PM
Saturday - Sunday: Closed

Our Team

  • Nick Ortiz
  • Jessica Ortiz
  • Dawn Keller
  • Tory Nelson

Practice Areas

  • Long Term Disability Insurance and ERISA Disability Insurance Claims
  • Social Security Disability Claims
  • Personal Injury Claims
  • Facebook
  • LinkedIn
  • Twitter
  • YouTube

Site Footer

©2020 Ortiz Law Firm, All Rights Reserved. Reproduced with Permission | Disclaimer | Privacy Policy

Share this ArticleLike this article? Email it to a friend!

Email sent!