Why Your Long-Term Disability Claim May Get Denied
When you’re facing a disabling medical condition that stops you from working, long-term disability (LTD) benefits can be a vital source of financial support. These policies, whether provided through an employer or purchased privately, are supposed to step in and help during some of the hardest moments in a person’s life.
But the truth is, insurance companies don’t always make it easy. In fact, it’s not unusual for a long-term disability claim to be denied, even when the disability is clearly documented and legitimate.
If your claim was denied, or if you’re preparing one and want to make sure it doesn’t get rejected, it’s crucial to understand every aspect of your policy and provide the strongest documentation possible. And remember, the skilled lawyers at Sandstone Law Group are here to help you navigate these denials and fight for the benefits you’re entitled to under your plan.
Let’s review the most common reasons why long-term disability claims get rejected.
Failure to Meet Policy Definitions
One of the most significant reasons for a denied LTD claim is failing to meet the policy’s specific definition of disability. Disability insurance policies vary in how they define disability, and these definitions can significantly affect your claim.
Some policies define disability as the inability to perform the duties of your own occupation, while others use a broader definition that requires you to prove you cannot perform any job for which you are qualified. This distinction can make a huge difference in how your claim is evaluated.
For example, under your own occupation definition, if you cannot perform the duties of your current job, you might be eligible for benefits. However, once the policy transitions to any occupation definition after a certain period (often two years), you must show that you cannot perform even a sedentary job that meets a wage threshold.
At this point, it becomes much harder to qualify for benefits, especially if the insurer argues that you could work in a different field.
Pre-existing or Other Disqualifying Conditions
Another major hurdle to a successful LTD claim is pre-existing conditions. Disability insurance policies often exclude coverage for conditions that were diagnosed, treated, or even suspected before the policy’s effective date. This is particularly common in group disability insurance plans, which often include a look-back period of anywhere from three to six months before coverage begins. If you received treatment or medication during this period for a condition that later leads to disability, your claim may be denied.
In addition to pre-existing conditions, many policies also exclude coverage for disabilities caused by self-inflicted injuries or injuries sustained while committing a crime. For instance, some policies may deny claims if the injury or illness is a result of driving under the influence of alcohol or drugs. Even conditions like drug or alcohol addiction might be excluded under certain policies.
Insufficient Medical Evidence
One of the most common reasons for denial is insufficient medical evidence. Disability insurers often require substantial proof of your condition to justify a claim. This may include test results like MRIs, X-rays, lab results, and psychological assessments. Without these objective test results or documentation that clearly explains the severity of your condition, your claim might be rejected.
For conditions that are difficult to quantify, such as pain or fatigue, the lack of measurable data can be a barrier. Insurers may dismiss these claims unless there is substantial documentation, such as functional capacity evaluations or neuropsychological testing, that shows the impact on your daily activities.
Lack of Continuous and Appropriate Treatment
Insurance companies often require that you follow a continuous and appropriate treatment plan to qualify for LTD benefits. If there are gaps in your treatment or you are not following your doctor’s recommendations, your claim could be denied.
For example, if you fail to see a specialist for a complex condition or miss prescribed treatments that could have improved your condition, this may raise red flags for the insurer.
Missed Deadlines and Incomplete Forms
In the disability claim process, timing is everything. Insurance companies typically require documentation within strict timelines, often within 30 to 90 days of the onset of your disability. Failing to meet these deadlines or submitting incomplete forms can lead to a denial. Missing paperwork is another common reason for claims being rejected.
Some states have specific laws (like the notice-prejudice rule) that require insurers to prove they were harmed by a late submission before denying a claim. However, in other states, especially for self-funded plans, strict deadlines apply regardless of the situation.
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