COMMON MISTAKES WHEN FILING A LONG-TERM DISABILITY CLAIM
March 24, 2022
No one in their 20s expects an unfortunate disease or event to keep them from working before reaching retirement. However, one in four of today’s 20-year-olds will face a disabling condition before retirement age that keeps them from working for a year or more, according to statistics. How many are prepared for that possibility?
People rely on long-term disability (LTD) insurance policies to help them survive the unexpected and unfortunate possibility of being out of work for an extended period. Even among those who purchase LTD policies at work or through private insurance brokers, almost half of their disability claims for benefits – 40 percent – are denied, or are honored but only with exclusions that limit the benefits available.
Why is this? The most common reason for an LTD claim being denied is a lack of sufficient medical evidence, which means that the applicant didn’t fully support the claim with documentation, including X-rays, test results, MRIs, physician statements, and vocational findings by professionals and even by friends and family.
If you have been denied an LTD claim – or even if you’re just starting to file a claim – in or around San Francisco or anywhere in California, contact The Law Office of Bennett M. Cohen, P.C. immediately.
We can help you assemble the documentation and evidence necessary to improve your chances of getting your claim approved or your appeal granted. We know how the LTD insurance industry operates, and we can step in to afford you a better chance of getting what you deserve.
MAKING A LONG-TERM DISABILITY CLAIM
Long-term disability (LTD) policies have provisions in them that protect the insurer’s liability. First and foremost is your policy’s definition of disability, and second to that is the elimination period, or the waiting period before you can receive benefits. Policies differ on the waiting period, which could be 90 to 180 days; in other words, half a year without any compensation.
As for the definition of disability, many policies start with your inability to perform the duties of your “own occupation.” Under this clause, the policy might state:
“Disability exists when, due to illness or accidental injury, you are not able to perform, for wage or profit, the material and substantial duties of your regular occupation.”
Then, after a lapse of time, maybe 24 months or less, the policy might state that to qualify as disabled you must be unable to perform the duties of “any occupation.” This means that you must be unable to work in any status in order to continue receiving benefits. If you can sit at a desk and answer phones, then you are able to work “any occupation.”
COMMON MISTAKES IN FILING FOR LTD BENEFITS
The most common error or omission that results in an initial denial of LTD benefits is simply filling out the insurance company’s form and then failing to back that up with what insurers consider “sufficient medical evidence.” In this sense, a note you make on your claim form that your back prevents you from working in your warehouse occupation might not be sufficient.
Your physician or medical group must provide substantial test results and other medical evaluation evidence, including X-rays, MRIs, and other documentation. The medical evaluation should include physician statements that indicate, for instance, your back condition prevents you from standing for X number of hours or lifting X number of pounds. Be specific.
If your disabling condition is chronic fatigue, the physician’s statement likewise should be specific, including the duration of the fatigue, its frequency, severity, or intensity, and how often you must lie down and rest because of your fatigue.
Your insurer may also request that you undergo what they call an independent medical examination (IME) with a doctor of their choice. IME doctors are being paid by the insurance companies, so they can be expected to side with the company paying them if at all possible after they examine you.
Make sure you take notes from the IME about the tests required of you and the questions asked by the doctor(s). Also, request a copy of the IME report, so you and your disability attorney can challenge the findings if necessary.
Insurance companies also might surveil you to see if you’re really disabled. This will include searching for you on your social media accounts and seeing what you post. If you upload pictures of you dancing at a party, that could be evidence enough that you’re not disabled.
LTD insurers also have been known to hire investigators to track you in public. Whenever you’re in a place where there is little or no expectation of privacy – whether in a market, at a restaurant, walking down a street, or even attending a religious service – they can capture you on film to show evidence that you’re not really disabled.
Another way for your insurer to deny your claim is through a pre-existing condition clause in your policy. Policies vary on defining and limiting coverage for pre-existing conditions, so you should always read the fine print.
Insurers have been known to interpret their pre-existing limitations and exclusions broadly. Many LTD policies contain “look-back” periods during which they search for any medical evidence of a pre-existing condition. The look-back period is often three months prior to the policy’s effective date but could be longer.
RELY ON LEGAL ADVOCACY YOU CAN TRUST
Given the insurance industry’s practice to limit what they call their “exposure,” you can expect a disability claim to be given extra scrutiny. For this reason, it’s a good idea to enlist the aid of an experienced LTD attorney in filing your claim, and certainly, if you need to file an appeal because of denial.
If you’re in the San Francisco area or anywhere in the Golden State, contact The Law Office of Bennett M. Cohen, P.C. for help in pressing your claim or appealing a denial. We know how insurance companies operate and can help you overcome hurdles thrown your way.