So you got a letter of denial or termination…
“There must be some mistake.” That’s a typical reaction after opening a letter from the insurance company informing you that your long-term disability claim has been denied. Your policy is current, you filed your claim on time, and you know that you suffered a disability, so what went wrong? The fact is that three million people apply for long-term disability benefits every year, and over half of them are denied. Why does this happen, and what do you do when it does? Read on for answers to these basic but vital questions.
Why was my claim denied?
Long-term disability benefits are a considerable expense for insurance companies, so if they can find a reason to deny your claim, they will. Common reasons include technical errors in your claim, such as failure to provide proof of loss in a timely fashion as required by your policy. When you sign an insurance policy, you may know what your premium is and what your benefits are, but the process for filing a claim likely remains a mystery until the day you need to file. Then you’ll find out just how esoteric and complicated an insurance contract can be. It is all too easy for the average policyholder to miss a technical detail that gives the carrier a reason to deny the claim.
The other main reason claims get denied is that the medical record is incomplete. You’ll need to provide more than just your doctor’s diagnosis and treatment notes. Medical evidence must be carefully constructed to describe the disability in terms of the functional limitations on your ability to work. Your doctor may or may not know how to go about this and may or may not spend the time necessary without your stressing how important this factor is. Your long-term disability lawyer can work with your doctor to generate the appropriate documentation and review medical records before they are submitted to the insurance company, to make sure they adequately justify your claim for benefits in the manner expected by the insurance company.
Why were my benefits terminated?
In some cases, you may be initially approved for benefits but then later denied. You would think that Long-Term Disability insurance would pay benefits over a long-term, but the carrier’s goal is actually to cut off those benefits as soon as they can. One way they’ll approach this is by constantly reviewing your medical condition, as often as on a monthly basis. The insurance company may continue to require updated documentation from you and your doctors with constant requests for cumbersome paperwork. They may even conduct surveillance or surprise visits as part of their strategy.
As more and more documentation is generated, there are simply more opportunities for the insurance company to claim there is an inconsistency in the record or that a particular record or report is incomplete or lacking in detailed information. This can be enough for the insurer to decide not to continue your claim, forcing you into a position to fight for continuation of benefits.
It’s also important to understand that the insurance companies often use statistical calculations to decide when you are able to return to work, without focusing on your individual circumstances. However, statistics don’t tell the story of the individual; your medical records do. If your benefits were cut-off while you were still disabled and within your policy limits, make sure your documents are in order and take the proper steps to fight that termination.
Follow procedures to appeal a denial
Calling your insurance company after receiving a denial letter may not only be fruitless and frustrating, it could damage your claim. You’re likely angry and in an emotional state, and you won’t be thinking about what should or shouldn’t be said from a legal point of view. That’s an understandable, human reaction. However, keep in mind that the insurance company is taking note of every word you say and building a case for defending the denial should you appeal. You can fight the denial, but let your attorney to do your talking for you. Experienced long-term disability lawyers know what to say and do and what not to say and do when responding to a letter of denial or termination.
Appealing a denial normally doesn’t involve going to court initially. First there is likely to be an administrative appeals process if you have a group plan through your employer which is covered by the federal benefits law ERISA. Alternatively, the insurance company may have its own internal review or appeals process that must be followed according to the terms of your policy. Insurance companies behave differently (and more reasonably) when an experienced LTDI attorney is involved in the appeal. If you are unrepresented, don’t expect the insurance carrier to clue you in to vital information, such as your deadline to appeal or the fact that any information or documentation not included in your appeal will likely never make it before a judge if you need to file a lawsuit on your claim.
