On employer-provided long-term disability (LTD) claims, there can be numerous issues surrounding a denial of a claim. It is common for disability applications to be evaluated by claims administrators usually working for your insurance company. Therefore, some deserving claims can get denied even when the evidence of disability appears to be clear. Understanding why claims are denied will help you present your best case possible at the administrative level.
One of the most common reasons for denial is insufficient medical evidence. Having detailed and supportive medical records are important in receiving LTD benefits. When you go for your regular medical treatments or physician appointments, be sure to discuss any important medical issues with your physician. Additionally, the physician probably will be ordering certain medical tests, including x-rays, MRIs, or CT scans, when necessary.
Another common reason for LTD claim denial is missing medical records. The insurance company may have failed to obtain all of your necessary medical records. Be sure that you ask your disability carrier for a list of the records it has requested and those it has received. If some records are missing, be persistent and make sure that your insurer requests the appropriate records.
A third reason you may be denied for LTD benefits could be related to your physician’s statement. Your insurance company may not have the correct statements from your physician so be sure that your physician’s office writes a letter that details how your impairment limits your work abilities. Then make sure that the insurance company receives that letter, and any other important documents or subsequent letters that come from the physician.
Submitting all medical evidence as soon as possible in the appeals process is important because federal courts typically are limited to considering only evidence contained in your administrative record. Your medical records or other evidence needs to have been submitted to your insurance company, prior to any federal court date.
Another common reason your LTD claim may be denied is related to your plan’s precise definition of ‘disability.’ Some plan policies define it as being medically unable to carry out the duties of your certain occupation. Other plan policies define disability as the inability to perform duties of any job. It is best to check with your LTD plan policy to avoid any unexpected issues.
It is important to check with your policy’s summary plan to look for any excluded medical conditions. Any medical impairments that may be related to substance abuse or pre-existing conditions are sometimes excluded from coverage. There also may be benefits that are limited when conditions are based on subjective complaints rather than objective testing. Some examples of these conditions are fibromyalgia, chronic fatigue syndrome, or depression.
Also, if you miss any important deadlines when filing and appealing your claim, it could cause more complications for your claim. Most group plans give you 180 days to appeal an initial denial. At this point, it would be best to hire an LTD attorney who can assist in obtaining your medical records and other important documentation to help get a favorable response for you.