Guardian Life Insurance Company is one of the nation’s well-known providers of long-term disability (LTD) insurance through both employer-sponsored and individual disability policies. While these policies are intended to provide financial protection when illness or injury prevents someone from working, obtaining, and maintaining benefits is not always a simple process.
Like many disability insurance companies, Guardian reviews every claim when it’s submitted and monitors approved claims for months and often, for years. Understanding how Guardian evaluates disability claims can help claimants avoid common pitfalls and be prepared if and when the time comes that benefits are denied or terminated.
The Policy’s Definition of Disability Is Critical
One of the first issues Guardian evaluates is whether the claimant meets the policy’s definition of disability. Medical records will be closely scrutinized to look for objective test results proving the disability is severe enough to warrant coverage. If the policy contains provisions excluding certain disabilities or preexisting disabilities, the claim may be denied. It’s important to have an original policy to review.
Any vs. Own Occupation Provisions
Many Guardian LTD policies begin with an “own occupation” definition of disability. Under this standard, benefits may be payable if the claimant cannot perform the material and substantial duties of their regular occupation.
After a specified period, commonly 24 months, many policies transition to an “any occupation” definition. At that point, the claimant must demonstrate that they cannot perform the duties of any occupation for which they are reasonably qualified by education, training, or experience.
This change in the disability standard is often when the claim is reviewed and terminated.
In contrast, Guardian/Berkshire provides Own Occupation Individual Disability Insurance – often for the duration of the coverage, which is typically marketed to doctors, dentists and other white collar professionals.
Medical Evidence Guardian May Require
Like any long term disability insurance company, Guardian requires medical documentation when evaluating disability claims. Claimants will be asked to provide medical records, a physician statement, results from diagnostic tests, medication history, occupational evaluations, employment records, and treatment records. Guardian may also contact treating physicians for additional information or clarification regarding the claimant’s restrictions and limitations.
Comprehensive and consistent medical evidence is often one of the most important factors in obtaining disability benefits.
But just being disabled isn’t enough to have a claim succeed. The records submitted to Guardian must outline the specific duties and tasks of the occupation and tie in how the disability makes it impossible for the person to perform these tasks. Otherwise, the claim will be dismissed as incomplete.
Ongoing Claim Reviews After Approval
Approval of a disability claim does not necessarily mean the review process has ended.
Guardian periodically reviews claimant’s eligibility throughout the life of the claim, especially if it is a large monthly benefit. They’ll ask for updated medical reports, lab tests, records of treatments and may request financial records.
Surveillance of any activities outside of the house should be anticipated. In addition, all insurance companies regularly monitor social media and online activities to uncover any proof of a person being able to work. Mischaracterizing social posts and surveillance videos is a common tactic used to terminate a claim.
Common Reasons Guardian May Deny or Terminate Benefits
Guardian may deny or discontinue disability benefits for a variety of reasons, including:
- Insufficient medical evidence.
- Lack of objective findings supporting the disability.
- Alleged improvement in the claimant’s condition.
- Inconsistent medical records.
- Failure to comply with treatment recommendations.
- Surveillance or investigative findings that appear inconsistent with reported limitations.
- Determination that the claimant can perform their own occupation or another suitable occupation under the policy.
A denial letter will explain the insurer’s reasoning, but our clients often find those letters to be very vague. We also advise clients not to use the insurance company’s descriptions of their appeal rights as their guide for response. Doing so could put the entire claim at risk.
The Importance of the Administrative Appeal
If Guardian denies a claim governed by ERISA, the administrative appeal is the claimant’s final opportunity to submit additional evidence before litigation. It’s important to note that once information is entered into the claim file, no new information may be provided. Doing this without the guidance of a seasoned long term disability insurance attorney could create a no-win situation for a claimant.
Appeals are complex matters, requiring thorough legal citations of prior LTD cases, medical research, and journal articles as well as personal statements from family members, employers and colleagues. Adding the latest doctor’s report to the claim file is not an appeal strategy.
A strong appeal may include:
- Updated physician opinions
- Functional capacity evaluations
- Neuropsychological testing
- Vocational expert reports
- Additional diagnostic testing
- Detailed statements explaining work-related limitations.
Building a sound administrative record is critical because courts reviewing ERISA claims are limited to the evidence submitted during the appeal process. It’s the last chance to prepare for litigation, and if it isn’t not handled right, could eliminate the possibility of ever receiving LTD benefits.
Protecting Your Guardian Disability Claim
Claimants can strengthen their disability claims by ensuring they are represented by a skilled LTD attorney. They also need to:
- Follow prescribed medical treatment.
- Attend all scheduled medical appointments.
- Maintain consistent communication with treating physicians.
- Ensure medical records accurately describe functional limitations.
- Respond promptly to Guardian’s requests for information.
- Avoid inconsistencies between reported symptoms, medical documentation, and daily activities.
Consistency throughout the claim file often plays an important role in maintaining eligibility for benefits.
Obtaining and preserving long-term disability benefits requires substantial medical evidence, ongoing documentation, and careful attention to the insurer’s requests throughout the life of the claim.
Guardian disability claims may involve complex policy language, detailed medical evaluations, and strict appeal deadlines. Claimants facing a denial or termination of benefits should consider speaking with an experienced long-term disability attorney before attempting to navigate the process alone. Proper preparation and a well-supported claim can make a meaningful difference in protecting valuable disability benefits.
