When people purchase long-term disability insurance, they do so with the expectation that benefits will be available if a serious illness or injury prevents them from working. Whether coverage is obtained through an employer-sponsored benefit plan (ERISA) or an individual or private disability policy, the promise is generally the same: if you become disabled and meet the policy requirements, the insurance company will pay benefits as promised in the policy.
Unfortunately, many claimants discover that obtaining or keeping long-term disability benefits is not always as straightforward as they expected. Like many large disability insurance carriers, The Standard Insurance Company closely scrutinizes disability claims and looks for reasons to deny or terminate benefits. While the company may argue it is simply enforcing the terms of its policies, claimants frequently describe a process that seems designed to make receiving benefits as difficult as possible.
Understanding the methods commonly used by The Standard can help claimants recognize potential problems before they jeopardize a disability claim.
Unique Policy Language in Some Standard Insurance policies
Some policies issued by The Standard contain broad language that often detrimentally impacts medical and/or legal professionals with their claims.
We have seen policies issued that address one’s own occupation being considered to be “the broadest scope of the license” – meaning that for a surgeon who might be disabled from surgery, they might not be considered disabled if they could still be a general doctor. Or a trial lawyer with orthopedic problems, who is denied because they can work at a desk. This is problematic contract language.
Lack of Objective Medical Evidence
One of the most common reasons The Standard gives for denying a long-term disability claim is an alleged lack of objective medical evidence.
At first glance, this may seem reasonable. Insurance companies want proof that a claimant is disabled. The problem is that many disabling conditions do not lend themselves to objective testing. Chronic pain, fibromyalgia, chronic fatigue syndrome, migraines, autoimmune disorders, and many mental health conditions often involve symptoms that cannot be fully measured by an MRI, blood test, or X-ray.
Despite this reality, insurance companies frequently demand objective proof of limitations. When the medical records do not contain the type of evidence the insurer wants to see, The Standard may argue that the claimant has failed to prove disability.
This places claimants in an impossible position. They may be suffering from a legitimate medical condition that prevents them from working yet are told there is insufficient evidence because no diagnostic test can fully document what they experience every day.
Missing Documents and Incomplete Medical Records
Many claimants report a frustrating cycle of repeatedly sending documents only to be told that records are missing or incomplete.
Medical records, physician statements, questionnaires, test results, and other supporting evidence may be requested multiple times throughout the claim process. Even after records are submitted by certified mail, email, or fax, claimants sometimes receive notice that the documents were never received or that additional information is still required.
Whether these situations result from administrative problems or something more deliberate, the effect on the claimant is the same. Benefits are delayed while the insurance company continues requesting information.
For disabled individuals who are already coping with serious medical conditions and financial stress, these repeated requests can become overwhelming. It is one reason disability attorneys routinely advise claimants to keep copies of every document submitted and maintain proof of delivery whenever possible.
Pre-Existing Condition Exclusions
Another common basis for denying disability benefits involves pre-existing condition clauses.
Many long-term disability policies contain provisions that exclude coverage for conditions that existed before coverage became effective. The language varies from policy to policy, but insurers often conduct an extensive review of a claimant’s medical history to determine whether a current disability can be linked to prior symptoms, diagnoses, or treatment.
Claimants are frequently surprised to learn how broadly these provisions may be interpreted. A medical issue that seemed unrelated years earlier may suddenly become the focus of the insurer’s investigation.
When The Standard determines that a disability falls within a pre-existing condition exclusion, benefits may be denied regardless of how serious the current medical condition has become.
The 24-Month Change from Own Occupation to Any Occupation
One of the most significant hurdles in many disability claims occurs approximately two years after benefits begin. Most long-term disability policies initially define disability under an “own occupation” standard. This means a claimant may qualify for benefits if they are unable to perform the substantial duties of their own profession.
After twenty-four months, however, many policies shift to an “any occupation” definition of disability.
This change dramatically raises the bar for continued benefits. The issue is no longer whether a surgeon can perform surgery or whether a dentist can spend a full day treating patients. Instead, the insurance company asks whether the claimant can perform any occupation for which they are reasonably suited by education, training, or experience.
Not surprisingly, many benefit terminations occur at this stage. Even when claimants clearly cannot return to their former careers, The Standard may argue that they can perform some type of alternative work and therefore no longer qualify for benefits.
Biased Medical Reviews
Insurance companies often rely on physicians and nurses who review medical records on their behalf. Many of these professionals haven’t seen a live patient in decades. While these professionals may be qualified in their fields, they are ultimately being paid by the insurance company.
Courts across the country have repeatedly recognized the inherent conflict of interest that exists when an insurer hires experts to evaluate claims it may ultimately have to pay.
Claimants and their attorneys frequently encounter reviews that are selective in nature. Medical evidence supporting disability may receive little attention, while isolated notes that appear favorable to the insurer are emphasized.
In some cases, the reviewing physician never examines the claimant in person. Instead, the opinion is based entirely on a paper review of medical records.
Yet despite never meeting the claimant, these reviewers are often given substantial weight when The Standard decides whether benefits should be approved or terminated. Insurance companies have a fiduciary duty to incorporate the treating physician’s reports, but these are often given lesser weight or even outright ignored.
Independent Medical Examinations That Are Not Truly Independent
Most long-term disability policies allow insurance companies to require claimants to attend an Independent Medical Examination, commonly referred to as an IME.
The name itself is wrong.
The physician conducting the examination is compensated by the insurance company, either directly or through a third party company that itself is often owned by the insurance company. Can such a report ever be independent? We don’t think so.
The outcome of an IME can have a significant impact on a disability claim. If the examining physician concludes that the claimant has fewer restrictions than reported by treating doctors, The Standard may rely heavily on that opinion when denying or terminating benefits.
For many disabled individuals, it is difficult to understand why a physician who spends a few hours evaluating them is given greater credibility than doctors who have treated them for years.
Functional Capacity Evaluations Can Become a No-Win Situation
One examination that deserves special attention is the Functional Capacity Evaluation, or FCE.
An FCE is generally performed by a physical therapist and is intended to measure physical abilities, endurance, and work tolerances. On paper, the process sounds reasonable. In practice, however, many disability claimants find themselves in a no-win situation.
If a claimant pushes through pain and performs well during testing, the results may be used to suggest they can return to work. If the claimant struggles during testing or declines to perform certain tasks because of pain or fear of injury, the report may characterize them as uncooperative or accuse them of failing to provide maximum effort.
The examination often fails to answer a critical question: whether the claimant can perform work activities consistently, day after day, on a full-time basis.
A person may be able to lift an object once, bend over once, or reach overhead once. That does not necessarily mean they can repeat those activities throughout an eight-hour workday, five days a week.
Surveillance and Social Media Monitoring
Technology has made disability investigations easier and less expensive than ever before. Insurance companies rely on surveillance and social media monitoring as part of the claims process. A photograph posted online, attendance at a family gathering, or video footage recorded outside a claimant’s home may become part of the insurer’s review.
The problem is that these isolated moments fail to tell the whole story.
A claimant may attend a social event for a few hours and spend days recovering afterward. A brief video clip showing someone carrying groceries does not necessarily reflect their ability to sustain competitive employment on a full-time basis. Nevertheless, these activities are frequently cited as evidence that a claimant is more functional than reported.
Claimants should assume that anything posted publicly online will eventually be found by the insurance company and used to mischaracterize their activity.
Delays, Lost Documents, and Communication Problems
Many claimants describe the disability claims process as a constant struggle to obtain clear answers.
Phone calls go unanswered. Emails receive no response. Documents must be submitted multiple times. Claim representatives change unexpectedly, forcing claimants to explain their situation over and over again. From the claimant’s perspective, the process often appears disorganized.
We believe there is often more going on than simple disorganization. Insurance companies have the resources to investigate claims thoroughly and challenge claimants when they believe benefits should not be paid. It is difficult to understand why those same resources cannot consistently be applied to processing claims efficiently.
Delays serve a purpose. The longer a claim remains unresolved, the greater the financial pressure on the disabled individual. Some claimants may ultimately abandon their claims simply because they become exhausted by the process.
Profits, Not People
At the end of the day, disability insurance is a business. Insurance companies collect premiums, evaluate risk, and attempt to remain profitable. Profits, not people, come first, despite provisions in the LTD policy and promises made in sales pitches.
Every approved claim represents a financial loss to the company’s bottom line, while every denied claim enhances the company’s profits.
Claimants often feel that the promises made when disability insurance is sold do not match the reality they encounter when they file a claim. Instead of receiving the support they expected, they find themselves defending every aspect of their medical condition and functional limitations.
Understanding the tactics commonly used during the disability claims process can help claimants recognize potential problems and take steps to protect their rights. The more thoroughly a claim is documented and supported by medical evidence, the better positioned a claimant will be when facing scrutiny from a large disability insurance carrier.
