Getting denied long-term disability benefits is stressful when you’re already dealing with serious health issues. Then the benefit payments stop, or never begin, and you are left wondering how you will cover groceries, mortgage, medication, or other basic expenses.
The insurer may say you do not meet its definition of disability. While this is certainly discouraging, it’s not necessarily the final word.
A denied disability claim does not necessarily mean that your condition is not serious enough to qualify for benefits. It means that the insurer believes there isn’t enough information to support your claim, disagrees with your doctors, or gets the impression that you are still able to work in some capacity.
Speaking with a disability lawyer can help you understand why your claim was denied, whether the insurer’s decision is reasonable, and what options you have to challenge it.
Why LTD claims get denied
Long-term disability insurance is supposed to replace part of your income when a medical condition prevents you from working. Coverage often comes through an employer group plan, although some people have private policies.
There are many reasons an insurer may deny a claim. It may say:
- There is not enough medical evidence.
- You can still perform the main duties of your job.
- You could work in another job.
- Your treatment records or claim forms have gaps.
- Your condition falls under a pre-existing condition exclusion.
- Surveillance, social-media activity, or other information does not appear to match your reported limitations.
- You have not followed a treatment recommendation.
- You do not meet the policy’s definition of disability.
Some denial letters are fairly direct. Others are full of policy language, references to medical reports, and opinions from people you may never have met. It is not always clear what the insurer is really saying, or whether its reasoning holds up.
The policy wording matters
LTD policies are not all the same. The exact wording can shape the whole claim.
Many policies change their definition of disability after a certain period of time. At first, the question may be whether you can do the important duties of your own occupation, while later, they may ask whether you can work in any job that is reasonably suited to your education and experience.
That shift can be a major issue. Let’s use an example: Peter may no longer be able to do his physically demanding warehouse job. His insurer may then suggest that office work is possible for him. But office work still requires certain abilities, like sitting for long periods or staying focused working at a computer. This new role must be feasible for Peter’s professional training and medical needs.
A legal professional can look at the definition that applies to your claim and compare it with the insurance company’s decision.
Medical evidence is often about function
A diagnosis is important but it is just not the whole story.
Your insurance company case manager really wants to know how your health affects your ability to function on a day to day basis in order to determine a baseline of what you can do. This can be difficult with conditions that change or flare up. Someone may look fine at an appointment, attend a family event, or manage a short errand, yet still be unable to hold down regular employment.
A lawyer may be able to help identify gaps in the evidence:
- Reports, records, and treatment notes from doctors and specialists
- Details about medication and treatment
- Functional abilities assessments, where appropriate
- Information about your actual job duties
- Workplace accommodation and attendance records
- Statements from people who understand how your condition affects you
The question is usually not whether you have a real diagnosis. The key issue is whether your condition keeps you from working in a regular and sustainable way.
Dealing with the insurer
LTD claims involve a lot of paperwork and documentation. You may be asked to:
- Complete forms
- Attend an assessment
- Authorize the release of medical records
- Take calls from a case manager
- Provide frequent updates
A lawyer will communicate with the case manager at your insurance company on your behalf, which will reduce the stress of trying to understand every request while you are unwell. It can also help make sure the information being provided is organized and clear.
You should still attend medical appointments, follow reasonable treatment advice, and pay attention to requests from the insurer. Hiring a lawyer does not mean you can ignore the claim process.
It does mean you have someone to ask when you are unsure what a request means or why the insurer wants certain information.
Keep an eye on deadlines
Deadlines matter in LTD claims. Missing one can seriously affect your options.
The denial letter may mention an appeal deadline, but that is not necessarily the same thing as the deadline to start a lawsuit. They are different issues.
Keep copies of anything connected to your claim:
- Your insurance policy or benefits booklet
- Denial letters and emails
- Completed claim forms
- Medical records and reports
- Messages with the insurer
A denied LTD claim can have a serious impact on your well-being. Getting legal guidance at the first sign of trouble can help you understand where you stand and know what your options are.
