If you have been denied long-term disability (LTD) insurance benefits, you are not alone. It is a frustrating experience, but a claim denial is not the end of the road. As a long-term disability insurance lawyer, I have helped scores of clients navigate the complex process of challenging a denied or terminated disability insurance claim.
Here’s what you need to know about a denied claim and how to overturn such a denial or termination.
Why was the claim denied?
The first step after receiving a long-term disability claim denial is to carefully review the denial letter from the insurance company. Disability insurance companies are required by law to provide a clear explanation of why they denied your claim. For many reasons, that might not always be complied with. Common reasons for claim denials include:
Insufficient medical evidence: The insurer may claim that your medical records don’t sufficiently support your disability. This is why I work with claimant’s doctors to make sure they have the diagnostic tests the insurance company looks for when considering a claim.
Lack of objective evidence: Some Policies indicate that Objective Medical Evidence must support a claim for disability benefits. Many do not, but an insurance company may seek to impose such a standard. We work to develop evidence, through clinical, diagnostic, testing, or other materials, to support our client’s disability insurance claims.
Policy exclusions/Limitations: Your condition may fall under an exclusion in the policy (e.g., pre-existing conditions or mental health limitations). A review of the policy before you file a claim can prevent this from happening or help to navigate the claim from inception. Often, you may have more than one disabling condition but knowing which one is more likely to succeed is important and how to potentially avoid invoking a limited benefit pay period.
Failure to meet the definition of disability: Some policies define disability in specific ways, and the insurer may argue you do not meet their criteria. Focusing on the occupational tasks and assembling a personal record of how and why you are unable to perform the tasks of your work is one of many ways I work to prevent claims from being denied.
Late submission or procedural errors: You may have missed a deadline or failed to follow a necessary procedural step when filing the claim. This is a serious error and might cost you the ability to fight back for your claim. Newfield Law Group helps clients avoid these and guides clients about timeframes, and deadlines with associated strategies.
Once you understand the reason for the denial or termination of your disability insurance claim, you can determine what actions are necessary to move forward with your case.
Review Your Insurance Policy or Secure it Immediately If You Can’t Find It
After receiving the denial notice, go back to your insurance policy. The terms of the policy play a crucial role in determining whether you have a valid reason to appeal the decision. If you do not have it, you must secure it.
Pay particular attention to:
- The definition of disability: Different policies define “disability” in different ways. Some may require that you cannot perform your own job, others only the similar occupation you perform, while others might require that you be unable to work in any occupation. Do you have an “own occupation” or an “any occupation policy”?
- Exclusions and limitations: Carefully read through any exclusions or limitations that could affect your claim, such as waiting periods or limitations on benefits for certain conditions. Most group policies, for example, limit mental health claims to 24 months. A common tactic is to switch your claim from a physical illness to a mental health illness if your medical records indicate any depression or anxiety, which is a frequent companion to a limiting physical illness. Newfield Law Group is familiar with this tactic and how to fight back against it and secure the maximum benefits you are entitled to.
- The appeal process: Your policy should outline the steps you need to follow in order to appeal a denial or termination of a claim. These can vary widely, so ensure you adhere to the timeframes and procedures specified.
If the denial relates to an issue within the policy’s terms, call our office to review your policy and discuss your claim. We can help you understand the policy language and determine whether the insurer is misapplying the terms.
Don’t Hesitate to Seek Legal Advice
Insurance companies are more focused on protecting their profits than providing you with the benefits you’re entitled to. Newfield Law Group’s decades of experience in LTD claims offers clients peace of mind in knowing they aren’t alone in fighting against the insurance company.
We offer a free review of your case and can provide you with an objective evaluation of your chances for a successful appeal.
Gather Additional Medical Evidence
One of the most common reasons for LTD claim denials is insufficient medical evidence. If your insurer rejected your claim due to a lack of supporting documentation, the best step is to work with an experienced long term disability attorney who can help your healthcare providers to create the information the insurance company is seeking.
- Contact your doctors: Request that your treating physician(s) provide more detailed reports, including how your condition limits your ability to work. We work closely with our client’s doctors to develop the appropriate language to address the issues that are open and need further addressing.
- Consider obtaining expert opinions: Depending on the nature of your condition, it may help to consult with specialists who can provide a more thorough assessment of your disability. We often consider additional testing to provide more powerful support to overturn the claim denial or termination.
- Ensure the documentation is current: Outdated medical records can be problematic. Make sure the records you provide to the insurer are as recent as possible and also that you are able to cover any periods that the insurance company identifies as needing support.
Jason Newfield helps clients determine exactly what kind of evidence is necessary to strengthen their claims. The goal is to create a robust, well-documented record that demonstrates your disability is real and debilitating. The goal is to win before court, and demonstrate to the insurance company why payment of the claim is the best and appropriate option.
Handling a Disability Claim Appeal
If you choose to appeal the denial, it is essential to adhere to any deadlines provided by the insurance company. Missing these deadlines can result in the permanent forfeiture of your right to appeal. Typically, insurance companies will allow 180 days (6 months) to file an appeal, but it varies based on the policy.
Your appeal should include:
- A written explanation: Clearly state why you believe the claim was wrongfully denied, referencing the policy and the evidence you have gathered.
- Additional documentation: Include any new medical records, expert opinions, or other evidence that supports your case.
- Any missing or incorrect information: If the denial was based on an error (e.g., you were incorrectly classified as not disabled), point out these mistakes and provide the correct information.
It’s crucial to submit a complete and well-organized appeal to improve your chances of success. We can help you ensure your appeal meets all the requirements and is as compelling as possible.
When Can You File a Lawsuit?
If your appeal is denied or ignored, you may have the option to file a lawsuit against the insurance company. In the U.S., the legal framework that governs LTD insurance claims typically falls under the Employee Retirement Income Security Act (ERISA), which can make the process complex.
ERISA claims: Under ERISA, lawsuits are generally limited to the administrative record—the documents that were considered during the appeals process. This can make it harder to introduce new evidence once the appeal is over.
Filing a lawsuit can be time-consuming and expensive, but in some cases, it may be the only way to secure the benefits you deserve.
Staying Organized is Challenging When You’re Too Sick to Work
The LTD claims process is slow and challenging, making it important to stay organized and persistent. Having an attorney on your site to handle all of the tasks involved, including maintaining correspondence, medical records, and other relevant documents as well as a timeline of all communication with the insurer, is more effective than trying to manage it on your own.
If your long-term disability claim has been denied, call Jason Newfield for a review of your situation and learn what you need to do to protect your claim.
