The Guardian Life Insurance Company of America sells its disability insurance products, which includes both personal individual disability and business disability insurance plans, through its affiliated company, Berkshire Life Insurance Company of America. However, it is Guardian that evaluates claims for benefits, pays benefits owed, and issues denial letters. Although Guardian Life is better than most other disability insurance companies in approving claims, there are still numerous claims every year that are wrongfully denied.
Nick Ortiz is a disability attorney with experience in appealing and litigating Guardian disability denials throughout the United States. Mr. Ortiz is available to provide you with a free consultation to discuss your legal rights and options while disputing your long-term disability claim denial. If you decide to create an attorney-client relationship, we will fight to help you obtain the long-term disability benefits that you deserve.
If your long-term disability claim has been denied by Guardian Life it is important that you take immediate action. The time period to submit an internal appeal with the insurance company is usually 180 days from the date of the denial. Once you have “exhausted” all of your appeals directly with the insurance company in an ERISA-governed claim, you may have a very limited period of time to file a lawsuit.
The Top 5 Reasons for Guardian Disability Denials
There are many, many reasons that your claim for disability benefits with Guardian Life Insurance Company of America could be denied, but the five most common reasons for a Guardian long-term disability denial are:
- Guardian Life’s hired physician reviews your medical records and the hired doctor issued a report stating that you are not very limited and therefore are not eligible for disability benefits;
- Guardian Life hired a private investigator to conduct surveillance and follow you around with a camera or video recorder. Guardian then used the video footage as evidence that you can return to work;
- Guardian Life sent you to be examined by a doctor of its choosing for an “independent medical exam” (or an IME for short, which is really not so independent) or for a functional capacity exam (FCE) to evaluate your restrictions and limitations;
- A doctor or nurse hired by Guardian spoke with your treating doctor and your doctor stated that you could return to work in some capacity; or
- The definition of disability under your policy changes from “Own Occupation” to “Any Occupation” after 12, 24, or 36 months, and Guardian hired a vocational expert to find jobs other than your own that you could presumably perform on a daily basis.
Social Security Approved My Claim, So Why Didn’t Guardian?
Unfortunately, being approved for Social Security Disability benefits does not guarantee that Guardian will approve your claim. The requirements to qualify for Social Security Disability are very different from the requirements to qualify for long-term disability benefits. Although you can use your approval letter from the SSA as evidence in your LTD case, you should know that it does not guarantee the approval of your long-term disability claim. If a significant amount of time has passed since you were approved for SSD, then Guardian may also argue that the evidence considered by the SSA during the claims process is no longer current, and therefore no longer relevant to Guardian’s decision.
How Does The Guardian Life Insurance Company Define Disability
Guardian Life prefers to issue long-term disability insurance to licensed professionals and business executives such as doctors, lawyers, accountants, and corporate and government employees. In order to participate in most Guardian Life group plans, you must be working in one of the following occupations:
- Attorney/Lawyer;
- Accountant/CPA;
- Architect;
- Dentist;
- Engineer;
- Mortgage Professional/Originator;
- Paralegal (or employed legal staff member);
- Optometrist; or
- Physician.
Since these are highly specialized occupations, most Guardian long-term disability insurance policies use an “Own Occupation” disability definition, at least for a certain period of time. However, some disability insurance policies transition from the “Own Occupation” definition to an “Any Occupation” definition after long-term disability insurance benefits have been payable for a certain amount of time. The definition of disability is unique to each disability insurance policy, but here is a typical “Own Occ” definition from the Guardian Life Insurance Company disability policy from a past claim:
Own Occupation Definition of Disability
A member is considered disabled if he or she has physical, mental, or emotional limits caused by a current sickness or injury and, due to these limits, he or she is: (a) not able to perform, on a full-time basis, the major duties of his or her own occupation: and (b) not able to earn more than this plan’s maximum allowed income earned during a period of disability. This own occupation definition remains in effect for your full benefit period.
For doctor’s (physician’s), own occupation means the medical specialty or subspecialty practiced by the doctor right before the start of disability, provided: (a) he or she is certified in such specialty or subspecialty by the American Board of Medical Specialties (ABMS); (b) he or she carries malpractice insurance covering the full range of duties performed in this specialty or sub-specialty; and (c) for the 24 months immediately prior to disability, at least 60% of his or her insured earnings was professional service fee income attributable to the practice of this specialty or sub-specialty.
Guardian Life Insurance Company Disability Claims: Is My Claim Governed By ERISA?
ERISA Claims
Many of the long-term disability policies Guardian Life sells are sold as group plans to employers. If a claimant is eligible for LTD coverage as an employer-provided benefit, then any disputes over a disability denial are usually governed by the Employee Retirement Income Security Act (ERISA). ERISA is a set of pro-insurance company regulations that creates a very high burden for claimants to overcome in a lawsuit against the disability income insurance company.
Non-ERISA Claims
If your long-term disability insurance is part of an individual disability income insurance policy, then your disability insurance claim may be exempt from ERISA regulations. In a non-ERISA case, you may not be required to file an appeal with Guardian. Furthermore, if your insurance company has failed to uphold its responsibility, you are able to file a lawsuit regarding the bad faith denial of your claim. ERISA policies, on the other hand, do not allow bad faith claims.
We Fight Guardian Life Insurance Company Disability Denials
We know that you often do not have the funds to pay your ordinary bills when you are hurt, disabled, and unable to work, much less pay for a lawyer to help with your claim for benefits. Thus, in our disability insurance lawsuits, we represent our clients on a contingent fee basis. Our clients do not pay us anything “out-of-pocket”. The Ortiz Law Firm advances all costs on the claim – like court filing fees, expert witnesses fees, court deposition fees, and electronic records subpoenas – and then we are paid an attorney’s fee entirely out of the disability benefits recovered.
Guardian Life may be one of the largest Life insurance companies in the U.S., but we will take on any LTD insurance companies. We bring claims against all the major insurance companies like Guardian Life, including Aetna, CIGNA Life Insurance, Hartford Life and Accident Insurance, Liberty Life Assurance, Lincoln National, Metropolitan Life (“MetLife”), Prudential Insurance, and Unum Life Insurance. We appeal denied disability claims involving all major disabling medical conditions, including:
- Claims where the insurer admits an injury but disputes the severity (such as spinal cord injuries and traumatic brain injuries);
- Claims where the insurance companies stubbornly refuse to admit a policyholder has a disease, like Crohn’s Disease, Degenerative Disc Disease, Lupus, and Multiple Sclerosis.
If you have received a long-term disability denial or termination letter from your insurance company, contact The Ortiz Law Firm for a free consultation. Please call us today at (888) 321-8131 for help obtaining the benefits you deserve.
Request a Free Evaluation of Your Guardian Long Term Disability Insurance Policy
If you are considering purchasing a Guardian disability insurance policy or have recently purchased a Guardian policy, we will help you understand what you are entitled to and whether there are deficiencies in your coverage that could lead to disability claim denials in the future. It is easy for policyholders who are not trained to read an insurance policy to misread or misunderstand the disability policy. We will review group disability and individual disability policies. As part of our evaluation, we will explain what everything means to you in your benefits claim.
Some of the most important aspects of your Guardian policy we will review include:
- Total versus residual disability;
- “Own occ” versus “any gainful occ”;
- Mental and nervous disability benefit limitations; and
- Self-reported conditions benefit limitations.