Long Term Disability Insurance Denials
There are a number of reasons the disability insurance company can deny your legitimate claim for benefits, even if you can't work because of an injury or medical condition. Unfortunately, most people don't recognize how important the appeal is, or, usually because they are so seriously injured or ill that it will be easy to convince the insurance company that they made a mistake, or they don't know how to respond (how would they, having never been in this situation before?)
Here's some common misconceptions about ERISA long term disability:
All it takes is reading the forms, telling the insurance company about your injury or illness and sending in a doctor's note.
If you just complete the 2 page form from the insurance company, you will get your benefits.
If you have been awarded Social Security disability benefits your long term disability benefits will automatically be approved by the insurance company.
If your doctor writes a note to the insurance company or your medical records indicate you are disabled you will be awarded disability benefits.
If your company or boss tells the insurance company that you can't work because of your illness or injury, you will be awarded benefits.
Here are some of the realities of ERISA long term disability:
Insurance companies are for profit corporations, with a duty to maximize profits for shareholders. One of the ways they do this is by denying claims like yours (and let's face it, they know a certain percentage of cases will go no further, and some people will just accept their denial).
The forms insurance companies send you are really to help them deny claims. By having you answer questions about things you can do that have no relationship to your work, injury or illness, they can say you're not disabled (or don't fit the policy definition).
If you're awarded Social Security disability, your insurance company can still argue that they do not need to follow that determination, even though it is a federal program and the standards for awarding social security disability are higher than most long term disability policies.
There is nothing that requires the insurance company to follow your doctor’s opinions and recommendations (even though that doctor knows your condition and limitations, has probably treated you over months or years and is in the best position to address this). Instead, they will probably hire an insurance medical examiner review your records, and somehow say you can work.
Just like with your physician, the insurance company is not required to follow your company's recommendation. Instead, they will ignore or minimize evidence from co-workers, bosses and people who are in the best position to observe your limitations, and especially the before and after picture.
What Can Do To Combat the Disability Insurance Company?
Here are some general tips to keep in mind as you go through the process:
Get prepared and organized. If you have a condition that is getting worse, get everything in order before you can't work and before you submit a claim.
Do not tell a lie in any part of the claims process. But with any forms you complete, send in all of your supporting documents as well - the forms themselves just aren't enough.
Get an independent lawyer to help with social security when you file for social security disability - the disability insurance company may offer a big national firm to do this for you - but whose interests do you think that firm and lawyer have at heart?
They don't teach ERISA disability claims in medical school. Your doctor may be an awesome physician but doesn't know what will help or hurt your specific disability benefit claim - above all, make sure he or she (or any physician you see) uses the definition of disability contained in the insurance policy. Sometimes the doctor may have a definition of disability in his or her own mind or practice that is different.
Get letters from bosses, co-workers, friends and families who can accurately describe your condition and how it prevents you from working (especially the before and after picture) and include them in your appeal, even though the insurance company may ignore or discount these. If nothing else, if you're appeal is denied and you have to file a lawsuit in federal court, you can argue their denial was unreasonable because they didn't consider this evidence.
And if your long term disability claim was denied, call us at (202) 393 - 3320 for help. We'll review the denial letter for free and tell you what we think. Just remember, under ERISA, you only have 180 days to file your appeal, so don't wait!