Hi, I’m Nick Ortiz. I’m a board-certified disability attorney in Florida. I’m licensed to practice law in the states of Florida and California, but I do handle long-term disability cases nationwide. Today, I’m here to talk to you about the top 10 reasons why insurance companies deny long-term disability claims.
Number one, 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 all there is 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.
Number two, 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.
The third reason why 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 activity that seems to contradict what’s in the medical records, then that can be used as a basis for a denial.
Number four, 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 allow there to be coverage if it’s a self-inflicted injury. Number two, let’s say that the injury was incurred during in the criminal activity, then 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 denial.
Number five, this is a common one. Insurance companies often denied 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.
Number six, there may be contradictory online evidence in your case. Social media is a big one, Facebook. Oftentimes, the insurance companies will go to your Facebook profile, download pictures that you posted, videos that you posted, and let’s say that they show you engaged in certain activities, then they may try to use that type of evidence against you in your case.
Number seven is fraud or misrepresentation. So let’s say that 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 a denial due to fraud or misrepresentation.
Number eight is treatment compliance. 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, so 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.
Number nine, the claimant must meet all the eligibility requirements under the policy to have coverage, and some of those requirements may be nonmedical 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.
And number 10, 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.
I hope this is been helpful for you. If you’d like to have a free case evaluation, then I encourage you to give us a call at 850-898-9904, but I also have a free resource for you. I wrote a book called the Top 10 Mistakes That Will Destroy Your Long Term Disability Claim, and I’m making that available for free download at www.freeltdbook.com. You go there, you can request a free copy today. We look forward to hearing from you. Take care.