A technical denial of a disability claim occurs when you are denied based on a non-medical reason. The most common reasons for a technical denial of a long-term disability claim follow below.
Primary Reasons for a Technical Denial
A long-term disability claim can be denied on the basis of a pre-existing condition. You will need to check your long term disability policy for the exact definition of a pre-existing condition, but most claims that are filed within one year from the date your policy became active would be subject to the pre-existing condition exclusion because the condition arose within the first 12 months of their employment.
A long-term disability claim can also be denied if the insurance company determines that you received treatment related to your disability claim before your insurance took effect. It is very important to ask for a copy of your policy and read the exact wording so that you know what could cause your claim to be denied. In your denial letter, the insurance company should have included the exact wording from the policy to explain why they denied your claim.
Here is a sample Pre-Existing Condition Exclusion clause:
Pre-Existing Condition Limitation
The Insurance Company will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Pre-existing Condition. A “Pre-existing Condition” means any Injury or Sickness for which the Employee incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a physician within 3 months before his or her most recent effective date of insurance.
The Pre-existing Condition Limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of Disability that begins after an Employee has been in Active Service for a continuous period of 3 months during which the Employee has received no medical treatment, care or services in connection with the pre-existing conditions or is covered for at least 12 months after his or her most recent effective date of insurance, or the effective date of any added or increased benefits.A Cigna Long Term Disability Insurance Policy, Effective 2013
Group policies in particular usually have a pre-existing condition exclusion. When an insurance company agrees to provide insurance to a large group, they have no way of knowing the full scope of health issues these employees may have. They are taking an unknown risk unlike when they insure an individual. Unfortunately, some individuals seek employment only to apply and receive LTD services to avoid having to work.
Therefore, most claims filed within one year of coverage will be automatically denied to protect the insurance company. If an individual works longer than a year (in most cases), the insurance company cannot deny the claim based on the pre-existing condition exclusion and has to actually assess the individual and their claim.
The insurance company will likely do an investigation into your health before you filed a claim if your claim falls under the pre-existing condition exclusion. This is usually the 90-day period prior to your claim, also referred to as the “lookback period”, but can be longer depending on the terms of your policy, which is why you need to read your policy carefully.
If the insurance company determines that you were treated, diagnosed, or even had symptoms of your disability during the lookback period, your claim can be denied. However, there are different views on what words like “treatment” or “consultation” mean. That is why each case needs to be examined individually by several professionals including doctors from both the insurance company, the claimant, and in some cases, a judge.
Another reason for a technical denial is missing your deadlines. When you are filing an appeal, you must meet all deadlines in order for the claim to be processed. Most individual and group plans under ERISA will give you 180 days to appeal an initial denial. During this time, it is wise to hire an attorney and provide that attorney with all the records you can to help stack the administrative record with favorable evidence that supports your claim.
It’s important to note that once you have exhausted your appeals you cannot provide additional evidence on the day of court to the judge. Everything you wish to present has to be given to the insurance company within that 180-day period for review. If you miss the 180-day deadline period, your claim will not be allowed to go before a judge because you did not exhaust all of your administrative appeals. Your initial denial notice should have your appeal deadline on the notice, so be sure to keep your letter so you can review it and submit it to your attorney.
Must Meet “Actively at Work” Status
You may also receive a technical denial if you do not meet “Actively at Work” status. The “Actively at Work” status has two provisions. The first provision is the individual filing the claim must meet the standard for a full-time employee-which is working a minimum number of hours. Usually, the minimum number of hours for a full-time position is between 30-40 hours per week. The actual number of hours required for your claim to be approved will be outlined in your LTD plan, so be sure to check your policy.
The second provision is the individual must be capable of Active work even during vacations. If the claimant is not able to work during a vacation period, then the claim will be denied on the grounds that they would have been unable to work during the vacation period.
It may be helpful to look at a real world example to understand this concept more. Let’s look at Cheney v. Standard Insurance. Cheney, a 20-year attorney at Kirkland & Ellis, had C-5 neck surgery in 2012. She last worked December 9, 2011, and claimed disability starting December 20, 2011 onward. When she went out on disability she first used two weeks of accrued vacation through to January 3, 2012. Then, she was granted six months of leave to July 2012.
She submitted a claim for Long Term Disability benefits under the firm’s ERISA plan in 2012. Under the policy, coverage ended when the employee ceased to be a “Member.” To be a “Member” the claimant has to be “Actively at Work.” This definition required the claimant to be capable of Active Work even during vacations. Standard argued she was not eligible for disability benefits because she could not meet the “Actively at Work” definition.
ISSUE: Whether Claimant was ineligible for benefits when she declared she was disabled and took vacation time?
TRIAL COURT HELD: Claimant was eligible for benefits because she continued employment when she took accrued vacation.
SEVENTH CIRCUIT HELD: REVERSED—Claimant NOT Eligible for Benefits.
“To be covered under this ERISA plan, the claimant must meet the definition of “Member, Active Work”. This definition required the claimant to be capable of Active Work even during vacations. Plaintiff had a two-week gap (December 20, 2011-January 3, 2012) when she admits she was not able to perform “Active Work.” Under this policy, she lost eligibility because she was disabled while taking a vacation, and disability leave did not bridge the eligibility gap.”
If you feel like your claim has been denied for a technical reason, there is still time to seek an attorney that specializes in long term disability law. Working with an experienced disability attorney will give you the best chance of getting the benefits you deserve. If you have been denied disability benefits, do not lose hope. Many people are denied benefits the first time they apply. You have the right to file an appeal and to get more information that may help your case.
While the process can be daunting, your expert disability attorney will be able to guide you through the process. Getting expert help is often the difference between being denied and being approved for benefits. An experienced long-term disability attorney can help you stay on top of your deadlines, help you gather your documents, assist you during field interviews, and give you guidance that will help you get your claim approved. They do not get paid until you win your case. You can seek help without worrying about upfront costs or unexpected bills.
The Ortiz Law Firm has successfully represented people in disability cases across the United States. If you would like to talk to an experienced disability lawyer about your claim, the Ortiz Law Firm offers a free consultation with no obligation to use our firm. During the call, you can ask any questions you have regarding your claim, and we will answer them. To see how we can help you win your long-term disability case, call us at (888) 321- 8131.