Your employer provides you with a long term disability (LTD) policy, that is supposed to cover you when you suffer from a debilitating disability preventing you from working.
You think you are protected, gather all of the necessary evidence and records, submit the application and wait. You wait, only to receive a letter from your insurance company denying your application.
Under ERISA, the Employee Retirement Income Security Act, the company issuing your LTD policy, is also the one who decides whether or not you receive benefits under the policy. So the insurance company will save money by denying your claim, and promptly denies your claim.
Sounds unfair, doesn't it? All is not lost. Under ERISA, you are allowed to appeal the denial. But in order to draft an effective appeal, you need to know why your application was denied. The following reasons are some of the more common excuses LTD insurance companies will use.
Plain and simple, you must have medical records proving your disability.
Regular medical treatment. In most cases, your disability will need to be supported by regular, periodic medical treatment. Most long term disabilities aren't diagnosed after one or two visits.
You will likely need to have regular visits with your primary care physician, and then followup visits with specialists, depending on your disability. But physical disabilities will need to be supported by doctor visits, specialists visits, imaging such as X-Rays, MRI's, CT Scans etc.
Incomplete medical records. Make sure the insurer has all of your records. If not, and your claim is denied, then ensure they get all the records with the appeal.
You don't get to submit any new evidence after the appeal, so verify all medical records are submitted.
Statement from your doctor.
Insurance companies will require your doctor(s) to submit a written statement regarding your condition, and functional limitations. They usually provide a pre-printed form, but this form is very short and limited in space, designed to make your application inadequate.
We have our clients' doctors prepare a Residual Functional Capacity Questionnaire for their doctor to review, and sign. This is a very specific, in-depth questionnaire that you submit with the Physician Statement.
You need to review your policy language for the precise definition of disability, to see if you can meet the requirements. There are two main categories of disability, and a hybrid that combines the two.
Under an "own occupation" policy, you are considered disabled if you are unable to carry out the normal duties of your particular occupation. This policy is the easiest for employees to meet the requirements.
Each policy will have differences in what they consider own occupation, and what constitutes a disability. If you meet the requirements, you can actually change careers, and still receive benefits under the policy.
This policy is worse for you. This requires you be unable to work in any occupation. Sample language may say:
You are unable due to illness or injury to perform all the substantial and material duties of any occupation for which you are fitted by education, training, and experience.
Now, if you were a medical doctor earning hundreds of thousands of dollars a month, and your disability prevents you from doing any type of work except sedentary, desk jobs paying a few grand per month, that would normally not qualify as gainful employment.
They will look at your training, your experience, your education to determine whether you are unable to perform any occupation.
A lot of employer provided long term disability policies will combine the two. When you are first disabled, you will receive benefits if the insurer believes you are unable to perform your own occupation. However, after a period of time the definition of disability switches. Usually you see this switch around 24 months, but sometimes it's as short as 6 months after the first day of disability.
This is when a lot of claims for benefits are denied. Because of the switch in the definition, the insurer usually requires more evidence proving you cannot perform "any occupation."
If your claim for benefits is large enough, your insurance company may hire a private investigator to follow you around and record you engaging in activities that are not consistent with your claim of disability.
These videos are highly misleading as it's usually hours and hours of tape, edited down to a few minutes that are most harmful to your case. If you can engage in strenuous activity for 10 minutes a day, and you do, they will record those 10 minutes and present it, even though those are the only 10 minutes you have each day before pain sets in and you're shut down for the day.
Just remember, if your doctor says not to do something, don't do it. It'll be good for your health and your claim.
You need to review your policy to find the deadline for filing appeals. It is usually 180 days from the date of the denial letter. That is actually not a lot of time.
Find the deadline date, and calendar it so you don't miss the deadline. If you miss the deadline, you may be barred from filing a lawsuit in federal court because you failed to exhaust your administrative appeals.
Don't take the chance. File the appeal on time, and as complete as possible. There is no such thing as too much information.
You may not be familiar with some of the requirements and deadlines that apply to your appeal. These are many rules and strategies you need to be aware of, to successfully fight for the claim benefits they owe you.