When applying for long-term disability (LTD) insurance benefits, you need to be aware that many claims are denied. Even if your disability insurance claim is initially approved, you need to be aware that your insurance company can terminate – or cut off – your benefits. If the insurance company decides that you are no longer disabled, they can terminate your benefits with very little notice that your disability claim was denied. In some cases, the claimant is unaware their claim has been closed until they do not receive their regularly scheduled payment.
Reasons Your Long-Term Disability Claim Will Be Denied or Terminated
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 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.
Pre-existing Medical Conditions
“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 kind of 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 relating 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. It’s a new and materially different condition that 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 back 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.
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 be required 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, then 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 on through the appeal process if your claim is denied.
Video and Social Media Surveillance by the LTD Insurance Company
It is possible that you will be under video surveillance for a short period of time if the claims adjustor handling your long-term disability claim thinks that 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 or the court.
Insurance companies are most likely to conduct video surveillance when they know you will be out and about. It is especially common when your insurer schedules 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 be successful in obtaining surveillance video.
The LTD insurance company can also monitor your social media accounts on platforms such as Facebook, Instagram, and Tiktok. 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 you riding a rollercoaster at the fair, but you claim to have a severe neck injury. Most people with severe neck pain would not be riding a roller-coaster. A disability insurance company may use this evidence to deny long-term disability claims.
After an Independent Physician Consultant Report 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 issued by your own 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?
If your long-term disability claim has been denied, and the insurance company cites your IME or IPC report as the determining factor, 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 obtain additional medical records and statements from your doctors disputing the IME or IPC report.
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 uses the reasoning that these illnesses are hard to prove with medical testing and lab reports. They can be faked or exaggerated. Although these illnesses are serious, you must prove 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. Here is some sample language that was taken from an Unum plan, which states:
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.
Self-reported symptoms mean the symptoms that you report to your doctor are not verifiable using tests, procedures, or clinical examinations typically accepted in the practice of 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.
If there is no objective medical evidence in your medical records to support your subjective symptoms and limitations, it is likely that the insurance company may deny your LTD claim. For example, here is a federal court case summary wherein a claim has been denied by Aetna and Aetna wins 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. For example, you may be seeing a primary doctor for overall health, but your treatment plan for your heart condition is with a cardiologist. In this situation, you want to make sure you always see your cardiologist who is required for your treatment plan. If you miss appointments or scheduled procedures, the insurance company will assume your condition is no longer as severe and may terminate benefits.
Most long-term disability insurance policies have an age limit. It’s usually retirement age between 62-67 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 your co-pays, reach out for help. Contact the insurance company and explain your situation, ask your doctor’s offices 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 of time. If you think your disability claim has been denied or canceled unfairly, you should look over 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 (866) 853-4512 to schedule a free case evaluation. We can help you evaluate your disability claim to determine if you will be able to access long-term disability benefits and how to move forward with the process.