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When applying for long-term disability (LTD) insurance benefits, you must know that many claims are denied. Even if your disability insurance claim is initially approved, you need to know that your insurance company can terminate or cut off your benefits. If the insurance company decides you are no longer disabled, they can terminate your benefits with very little notice that your disability claim was denied. Sometimes, the claimant is unaware their claim has been closed until they do not receive payment.
There are multiple reasons long-term disability coverage can be denied or canceled. Whether you have coverage under a group plan governed by the Employee Retirement Income Security Act (ERISA) or an individual disability insurance policy, it’s always important to review your policy for reasons your benefits can be terminated. Here, we will touch on the most common reasons your long-term disability claim will be denied.
Long-term disability insurance companies oftentimes deny claims because they say there is insufficient evidence or objective medical findings 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 cognitive deficits or difficulty in thinking and processing information are an issue, then a good piece of evidence may be neuropsychological testing. This is the type of evidence an insurance company seeks to evaluate a case.
You Do Not Meet the 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. 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 policy.
Another part of the definition is that it often changes over time, such that after two years, it’s not just whether you can do your job but whether you can do other occupations. Be aware of how the term disability is defined in your policy.
Clerical or Procedural Errors
There may be clerical or procedural errors in the claim. For example, the claimant, their doctor, or their employer may not have filled out a necessary form to process the case or completed it incorrectly. Another procedural error is that the claim wasn’t brought in time. In most cases, you have a specific time limit within which to bring your long-term disability case to the insurance company’s attention.
Failure to Provide Required Documents
Missing deadlines or failing to submit necessary medical records and documentation requested by the insurance company can result in the denial or suspension of your disability benefits.
Reassessment of Your Medical Condition
Periodic reassessments of your medical condition are common in long-term disability claims. If there is evidence of medical improvement in your condition that suggests you are no longer fully disabled, or the insurance company determines you no longer meet the criteria for disability, they may cease your payments.
Not Applying for Social Security Benefits
Did you know that under most long-term disability insurance policies, the insurance company can require you to apply for Social Security Disability (SSD) benefits? If approved for long-term disability benefits, you may have to apply for SSD. The reason is to help offset the payment of disability benefits by the insurance company. Under most policies, if you are approved for SSD, the insurance company will only have to pay you the difference between your Social Security Disability benefit amount and your long-term disability benefit amount. This will save the insurance company lots of money. Failure to comply could result in the termination of disability insurance claims, so you should continue through the appeal process if your claim is denied.
Video and Social Media Surveillance by the LTD Insurance Company
You may be put under surveillance if the claims adjustor handling your long-term disability claim thinks you are not being entirely truthful about your symptoms and limitations. During this time, the insurance company can hire a private investigator to monitor your activities and take pictures or videos of anything they see that contradicts what you have told the insurance company.
Insurance companies will likely conduct video surveillance when they know you will be out and about. Insurers regularly schedule surveillance concurrently with an independent medical examination (IME). Since the insurance companies know you will have to leave your home to attend the examination, they can be confident that the investigator will successfully obtain surveillance video.
The LTD insurance company can also monitor your social media accounts on Facebook, Instagram, and TikTok platforms. All too often, disability claims are denied because the claimant’s posts and photos contradict the symptoms and limitations you reported to the insurance company.
For example, you post a picture of yourself riding a rollercoaster at the fair but claim to have a severe neck injury. Most people with severe neck pain would not be riding a rollercoaster. A disability insurance company may use this evidence to deny your long-term disability claim.
After a Peer Review or Independent Medical Examination
We frequently review cases where the long-term disability claim was denied following an independent physician consultant report or an independent medical examination. The insurance company can have your disability claim reviewed by an “independent physician consultant” (IPC) or “peer review” physician, or you could be scheduled for an independent medical evaluation (IME), which is an exam conducted by medical professionals that are not associated with your case currently.
In both situations, the “independent” physician probably hasn’t reviewed all of your medical records (if any) and will likely issue a report questioning any opinions published by your treating physicians and asserting that the medical evidence does not meet the definition of disability.
My Doctor Says I Can’t Work, So Why Was My Claim Denied?
Your claim may be denied even if your doctor says you can’t work. Suppose your long-term disability claim has been rejected, and the insurance company cites your IME or IPC report as the determining factor. In that case, you need to consult a long-term disability attorney. This is not the end of your disability case.
An LTD attorney can hire medical experts to conduct another IME on your behalf and hire vocational experts to support the fact that you cannot work. There could be missing medical records, which our law firm can help to obtain. We will also work to get additional medical records and statements from your doctors disputing the IME or IPC report.
Policy Exclusions and Limitations
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. Many policies will say that you cannot receive coverage for an injury you received while engaged in criminal activity, so that could be another basis for the denial.
There may also be a cap on how long claims for certain illnesses or injuries can be paid. Two-year maximum benefit periods often apply to claims for mental health disorders, non-verifiable conditions, and other chronic musculoskeletal and neuromuscular medical conditions.
This is common: insurance companies often deny claims based on a pre-existing medical condition. A pre-existing medical exclusion will often apply if the employee 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 in the three months before your employment began, then your pre-existing condition may be excluded from coverage.
Your insurance company’s definition of a “pre-existing condition” will be stated explicitly in your policy. A sample clause from an Aetna long-term disability policy is as follows:
“No benefit is payable for any disability that is caused by or substantially contributed to by a pre-existing condition or medical or surgical treatment of a pre-existing condition and starts before the end of the first 12 months following your effective date of coverage. A disease or injury is pre-existing if, during the three months right before your effective date of coverage, it was diagnosed. Or you received medical treatment, care, or services for the disease or injury. Or you took drugs or medicines prescribed or recommended by a physician for the disease or injury.”
Let’s say your effective date of coverage is January 1, 2021, and that you went out of work in April of 2021 due to a heart attack. The insurance company gets all the medical records, and they go back to October, November, and December 2020 to see if you were getting any treatment for a heart problem and found that you were taking blood pressure medication for high blood pressure.
The insurance company is going to argue that this treatment was related to a heart condition or that you took drugs or medicines prescribed or recommended by a physician for treatment of that type of condition, and the insurer may deny your claim because you were experiencing blood pressure problems during the lookback period.
In that type of case, our disability lawyer would argue that there’s a distinction between high blood pressure and ultimately stopping work due to a heart attack. A new and materially different condition caused you to stop working. You’ll need to identify either A) a condition that you did not get treatment for during the lookback period or B) that your condition is so materially different than what you received treatment for during the lookback period that it does not meet the criteria for pre-existing conditions, and that you should still be entitled to LTD insurance benefits.
Mental Health Conditions
Most long-term disability policies have a maximum payout of 24 months for a disability claim for mental health conditions. These conditions could include medical conditions like depression (including postpartum), bipolar disorder, PTSD, and anxiety. The insurance company claims these illnesses are difficult to prove with medical testing and lab reports. They can be faked or exaggerated. Although these illnesses are severe, you must verify the existence of your illness and the resulting limitations. That is very hard to do.
Self-Reported Symptoms Limitation
Many insurance companies are limiting long-term disability insurance coverage for non-verifiable medical conditions such as migraine headaches and fibromyalgia under the self-reported symptoms limitation clause of the LTD policy. This clause is sometimes called the non-verifiable condition limitation.
Self-reported symptoms mean the symptoms you report to your doctor are not verifiable using tests, procedures, or clinical examinations typically accepted in medicine. Examples of self-reported symptoms include, but are not limited to, headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness, and loss of energy.
Here is a sample clause taken from a Unum plan:
Disabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness, alcoholism or drug abuse have a limited pay period up to 24 months.
If there is no objective medical evidence in your medical records to support your subjective symptoms and limitations, the insurance company may deny your LTD claim. For example, here is a federal court case summary wherein Aetna has rejected a claim. Aetna won the argument that an insurance company can require objective medical evidence of functional limitations.
Chronic Medical Conditions
Some LTD policies have a maximum payout for chronic illnesses like arthritis, back pain, and carpal tunnel syndrome. Conditions associated with lifestyle choices like alcoholism, COPD from tobacco use, or other diseases related to drugs or alcohol use could result in termination of benefits after 24 months or less. Check your policy for possible limitations based on these types of conditions.
Not Continuing Your Treatment Plan
To prove that your condition is severe enough to receive long-term disability benefits, the claims adjuster will ask you to submit proof that you are continuing treatment. Your treatment plan for your condition may be supplemental to your general healthcare. Claims are often denied because the claimant is not receiving appropriate care or is not following their doctor’s prescribed treatment plan.
- If the doctor prescribes a specific treatment that may improve the claimant’s medical condition to the point where they may even be able to return to work, but the claimant’s not undergoing that treatment, that can be a basis for denial due to non-compliance.
- If you are seeing a primary doctor for overall health but your treatment plan for your heart condition is with a cardiologist, you want to ensure you always see your cardiologist, who is required for your treatment plan.
- Try not to miss any of your scheduled appointments, and if you do, be prepared to explain why. If you miss appointments or scheduled procedures, the insurance company will assume your condition is no longer as severe and may terminate benefits.
The claimant must meet all the eligibility requirements under the policy to have coverage, and some of those requirements may be non-medical. 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. 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.
Even if your claim is initially approved, most long-term disability insurance policies have an age limit. It’s usually retirement age between 62 and 67 years old. There are some exceptions to this – like if you apply for benefits over the age of 60, your benefits may have a “minimum benefit period” that may extend into the claimant’s initial retirement years. Check your policy for the exact wording on age-out dates and restrictions that apply to your long-term disability claim.
Many long-term disability claims are terminated because the claimant returns to work while receiving LTD benefits. Remember, the reason behind receiving benefits is you are saying you can’t work. Going back to work would most certainly disprove that. If your long-term disability payout is not enough to pay for your basic living needs and co-pays, reach out for help. Contact the insurance company and explain your situation, ask your doctor’s office to work with you on a payment plan, or consult a disability attorney for your options.
Request a Free Consultation with a National Long-Term Disability Insurance Attorney
There are many reasons why long-term disability claims are denied or why an insurance company may terminate your disability claim. Using these situations as a guide can help you continue to receive benefits for a more extended period. Suppose your disability claim has been denied or canceled unfairly. In that case, you should review your policy and consult a long-term disability claims attorney as soon as possible, as you only have a limited time (usually 180 days) to start the appeals process.
Although based in Florida, the Ortiz Law Firm represents claimants across the United States. We have handled disability cases with all of the major disability insurance companies. If you’d like to speak to an experienced long-term disability lawyer, contact us at (888) 321-8131 to schedule a free case evaluation. We can help you evaluate your disability claim to determine if you can access long-term disability benefits and how to proceed.Get a Free Case Review