If you have long-term disability insurance, you probably assumed that making a claim would be relatively easy. If you have had your claim denied, you may have rights under the Employee Retirement Income Security Act (ERISA). An attorney familiar with ERISA appeals may be able to help you.
But what are some common reasons for these claims being denied?
Missing a deadline
Both initial claims and appeals have deadlines. If you missed the deadline for your initial claim, do not miss the deadline to appeal. You have 180 days from the denial of your claim to appeal.
Failure to prove your disability meets the policy definition
Check whether your policy specifies whether your disability must keep you from pursuing your “own occupation” or “any occupation.” If the latter, you will need to prove you are unable to perform the duties of any job. Additionally, an “own occupation” plan can change to an “any occupation” plan after a certain length of time, which should be stated in your policy. And, there could be specific restrictions in what your plan considers to be a disabling condition. Some plans, for example, exclude preexisting conditions, substance abuse and other illnesses, no matter how disabling.
Failure to provide sufficient medical evidence
In order to prove that you have a disabling medical condition, you will need medical records that support your claim. Generally, you will need to be engaged in regular medical treatment. Also, your doctor and healthcare providers should ideally give you objective tests that show you have the condition. And, a detailed statement from a doctor confirming your diagnosis and how it affects your ability to work is very helpful. Finally, make sure your insurance company actually obtains all of your medical records. Claims have been denied based on missing records, so ask for a list of the records they have obtained.
Private investigators get evidence that you aren’t disabled
These days, it’s only too common for insurance companies to order surveillance on people making long-term disability claims. They’re typically looking to obtain video of you performing activities that you claim you are unable to do.
First, always follow your doctor’s orders, even when they seem excessive. For example, if your doctor says not to lift more than 5 pounds, don’t lift more than 5 pounds even if you think you can. Your health – and your disability claim – could depend on it.
You may have good days and bad days. You may be able to perform tasks on good days that you can’t perform on bad ones. Just because an insurance company says they’ve caught you doing something you claimed you couldn’t, don’t assume your claim should be denied.