Denial of long term disability (LTD) claims are a common issue for employees across the nation. Studies suggest that anywhere between 20 to 50 percent, and even as high as 60% of LTD claims are denied, leaving policy holders in a difficult financial situation.
Common Reasons for LTD Benefit Denials
There are a variety of reasons the insurance company may give for denying an LTD claim, often prompting a policy holder to appeal the decision:
Insufficient Medical Evidence is a common reason a LTD claim is denied. Insurers may decide that the insured party lacks evidence that the disability meets the plans definition, often defined as “an inability to perform job duties”. For example an insurer may deny an employee’s claim that they cannot work for lack of objective medical evidence such as lab results, imaging, or other verifiable tests to support their claim.
Policy Exclusions may include preexisting conditions diagnosed or treated within a specified period before the policy start date unless an employee has been symptom free for a set period of time; self-inflicted injuries caused by intentional self-harm, suicide attempts, or substance abuse; mental health or subjective conditions without objective medical evidence as define in plan. It is important for an employee to read and understand their policy for possible exclusions to coverage.
Surveillance Showing Misrepresentation of disability may result in denied benefits. Surveillance can be used to verify whether a claimant’s reported limitations align with observed behavior and may include in-person observation or social media surveillance and other online activity tracking. An insurer may use inconsistent findings to challenge a recipient’s claim resulting in denied benefits.
Administrative Errors might include administrative errors, missing documentation, incomplete or forms, or failure to follow claim procedures. Working with an experienced attorney can help recipients avoid mistakes that can lead to denied appeals.
Disability Definition Disputes often come into play when policies shift from “own occupation” to “any occupation” standards often after a period of 24 months. During the own occupation period (typically 1-2 years as specified in policy) a claimant is considered disabled if they cannot perform the material and substantial duties of their (own) specific occupation. After that, disability may be defined as in inability to perform duties of any occupation for which they are reasonably qualified by education, training or experience – a potentially higher threshold to qualify for disability benefits.
Offsets are when benefits are reduced if income from other sources are involved such as social security disability or workers’ compensation benefits. Offsets are designed to prevent over insurance, ensuring that total income does not exceed a certain percentage of the claimant’s pre-disability earnings (typically 60-80%). For example, most policies will offset benefits dollar for dollar by the amount received for SSDI, whether it is for the same or another condition. As for workers’ comp, a policy may offset the full monthly amount or prorate a workers’ comp lump sum settlement payment received over a period of months to reduce LTD benefits.
Contact an Experienced Denied LTD Disability Benefits Lawyer
If your long term disability claim is denied by the insurance company, it is important to consult an experienced denied long term disability benefits lawyer who can help you navigate the complex appeals process, and if necessary, pursue legal action against the insurer for denying your benefits. Many LTD policies have strict time limits for filing an appeal, so it is crucial to act promptly with expert legal representation. Contact the experienced long term disability insurance denial attorneys of Alan C Olson & Associates for immediate assistance and please visit our My LTD Benefits Website for more information regarding your denied LTD claim.
