Long-term disability (LTD) insurance exists to cushion you from the financial burden of the inability to work due to a long-term illness or injury. The benefits from the coverage help you pay monthly bills when an injury or disease you are insured against prevents you from working. However, you must submit a claim with your insurer, and when successful, you begin to receive your benefits.
Unfortunately, your insurance could deny your LTD claim even when qualified. A claim denial can be profoundly distressing, as it imposes a financial burden and emotional suffering when you are already dealing with a severe health threat. However, you should take the claim denial letter as a setback and appeal the decision. Here are the rationales for the LTD claim denial and the process of appealing the unfavorable decision.
Reasons for LTD Claims Denial
You will likely feel devastated when your insurer rejects your LTD claim. However, the denial letter you receive after the unfavorable decision should act as a blueprint or guide for an appeal. However, before filing the appeal, you should understand the reasons for rejecting the initial claim, so avoid your previous mistakes and enhance the chances of a successful appeal.
One common reason for claim denial is the incorrect filing of claims, which includes missing the deadline or submitting the wrong forms. So, when you fail to notify the insurer promptly about the claim and provide the correct forms, they will reject your claim. Insurance policy providers require immediate notice and persistent follow-up on the long-term injury or disease. If you fail to do this, the company might delay or reject your claim, even because of reasons tied to the ailment. This is not to mean that your claim is invalid. The procedural errors are the reason for the denial.
Similarly, failure to furnish the insurer with all the relevant documents proving your disability is grounds for a claim rejection. You will require comprehensive medical reports, physical examination reports, and results from objective tests for a solid claim. The insurer depends on the evidence you provide to rule for or against the benefits. Therefore, provide detailed information or evidence regarding your LTD to avoid claim delays or rejection. If the insurer finds the evidence provided insufficient, you will receive a denial letter.
Also, a conclusion by the insurance company that your injury or illness does not qualify as long-term disability will result in a denial. Every insurer has strict policies defining disability, and you must prove that your injury satisfies the policy requirements. For instance, an insurer can demand that you prove that you cannot perform any other job you are qualified for apart from your profession. If you can perform another job you are qualified for, even with the disability, the insurer will reject your LTD claim.
Additionally, you will not receive LTD insurance benefits if your policy does not provide coverage or the insurance plan administrator considers the condition preexisting. The exclusionary duration for preexisting conditions ranges from as little as three months to 24 months. So, if you had symptoms or sought treatment for a condition not insured against within this exclusionary window, the insurer will deny your LTD claim. Insurers only accept claims for which the conditions are covered.
Lastly, insurers are in the business of making profits. Do not assume they are passive arbiters because they will conduct independent investigations to find reasons to deny your LTD claim. They will hire medical experts to dispute your medical report, monitor your activities, and monitor hospital attendance. When you fail to seek medical treatment for the condition regularly or participate in activities that your condition renders impossible to perform, the insurer will have grounds to reject your LTD benefits application.
Obtain Your Insurer’s LTD Insurance Policy
If you have not yet obtained a copy of your insurer’s LTD insurance policy, consider obtaining a copy. Group insurance holders can obtain a copy from their company's human resource department, while individual policyholders can directly contact their insurer for a copy.
However, requesting a copy of the insurance policy is not as easy. If your HR or insurer fails to send a copy, you can send a certified mail to your insurer’s plan administrator. The Employee Retirement Income Security Act (ERISA) requires the administrator to furnish you with a copy of the summary plan document.
Study the LTD Denial Letter
When your insurance company rejects your LTD claim, they will send a denial letter detailing the reasons for their decision. Even though you feel devastated, meticulously study the letter to understand the reasons for the rejection and the guidelines for appealing. Every denial letter, regardless of the validity of the insurer’s decision, must provide details crucial for an appeal, such as:
- The reasons for the denial
- A review of the summarized evidence that led the insurer to the decision
- The parties that studied your claim, like consulting doctors or nurses
Failure to study the denial letter carefully means you will not understand the reasons for the unfavorable decision or the mistakes you made during the application that led to the rejection. You could repeat the same mistakes when appealing the decision, leading to another unfavorable decision.
Before appealing the LTD claim, understand the reasons for the denial under your specific policy, the technical errors or mistakes resulting in the rejection, and the insurer’s general policies and how they led to the unfavorable decision. With this information, you can file an LTD claim that not only mentions you have a disability but also provides comprehensive evidence and is free of technical issues. Focus on building a flawless administrative record anchored on targeted evidence.
Steps for Appealing an LTD Claim Denial
Now that you are familiar with the reasons for the initial insurance claim rejection and what you need to file a successful appeal, it is time to start the appeal process. A denial is only a challenge to securing your LTD insurance benefits. ERISA governs most group LTD insurance plans that employers sponsor. If you belong to this plan, you must file an administrative appeal, which acts as a record for other litigations. Therefore, you must ensure the appeal is perfect because even if the case goes to the federal court, the judge will study the proof in the administrative record to issue a verdict.
You only have 180 days after the denial to lodge an appeal. If you miss the deadline, you will relinquish your appeal right, meaning you will have exhausted your option for claiming LTD insurance benefits. It is difficult to balance between appealing the decision within the provided timeline and recovery from your condition. The mental anguish from the disability and the setback even increases the risk of delaying an appeal, waiving your rights to the LTD benefits completely. Therefore, it is crucial to have an LTD claim attorney on your side and it is crucial to handle the appeal while you focus on recovery. The legal representative will file the appeal correctly and within the set time.
Collect Missing Details
If the LTD benefits claim was rejected because of technical problems, like completing the wrong forms or not submitting all the requisite forms, ensure you include the omitted forms and correct forms in the appeal letter. Besides, check with your insurer to ensure they have all your medical reports.
Insurance companies can miss out on some crucial medical records in winning your insurance claim. Contact your insurer to establish the medical documents they relied on to deny your claim. Besides, you want to know when the insurer requested and received the medical reports. If some of the reports are missing, you should notify your attorney to find them and attach them to the appeal.
Retain the Services of an LTD Insurance Claim Attorney
You should partner with an experienced attorney when you discover that your LTD plan covers your condition. Many claimants take these claim processes lightly and file in person. Because they are unfamiliar with the process, they submit late claims, provide insufficient evidence, or make technical errors during filing, leading to rejection of claims. So, you should hire an attorney familiar with these claims from the start of the case to minimize the chances of a denial. Do not wait until you receive a denial notice to hire an attorney.
However, even if you did not enlist the services of a legal representative in the initial filing, it is not too late to introduce one on the appeal because this is your last shot at securing LTD benefits. A competent attorney will obtain all the new evidence required, such as medical reports and testimonies from vocational and medical professionals. Having filled many claim forms in the past, the attorney is unlikely to make technical errors, increasing the chances of a successful appeal. Besides, your plan administrator or insurer will take your case with the gravity it deserves if you have legal representation.
Not every attorney can guide you in the initial filing or appeal. You must find an attorney knowledgeable in ERISA statutes and who has won many claims like yours, to increase the chances of a successful initial claim or appeal. Do not worry about the cost of the private LTD attorney, as they work on a contingency basis. When they win the case, you will only pay them an agreed-upon fraction of the claim settlement. If you lose, the attorney will not receive any payment.
Stack Your Administrative Record with Evidence
If you want your appeal to be successful, you must stack it with solid evidence before finishing the insurer’s internal appeal process. Internal appeal decisions might not always be in your favor, so you should prepare to go to court. The challenge with taking the case to the federal court is that they only review proof on the administrative record. So, the court will not consider any evidence, however strong and convincing, that is not in the record or was not presented to the plan administrator.
In the internal appeal process, the company administers questionnaires and other forms to acquire more information about the claim. Some of these questions or paperwork seek to obtain information about the injuries. Ensure you answer the questions truthfully because incorrect or false details could be grounds for an appeal denial. In addition to answering the questions truthfully, you should attach medical records to support the information provided.
Provide Objective Evidence
Insurers reject many claims because claimants do not provide objective evidence. You should submit an appeal that anticipates and challenges the insurance company’s arguments against your claim. The cornerstone of the evidence is detailed medical records, vocational and medical expert testimonies, and your side of the story.
An insurer can argue against subjective proof, like statements from friends and relatives about your condition and self-reported symptoms. However, they cannot contest objective evidence, like lab test results, MRIs, CT scans, and X-rays. Also, they cannot challenge the clinical condition observed by your medical expert.
Therefore, find the objective proof to strengthen your appeal further and provide it. You can even include written statements from your physical therapist (PT), Mental health professional, or doctor. Statements from these experts will explain your injury or illness and how it permanently restricts you from performing your work duties.
Additionally, your attorney can obtain an opinion contrary to your insurer's regarding your condition.
Disability means you can no longer perform your duties. It means in addition to the testimony from medical experts, you will require the testimony of a vocational expert.
Provide Clarifying Statements from Your Treating Medical Doctors
Insurers look for mistakes or inconsistencies in the medical report that they can use to deny your claim, but they might not meticulously study it. Errors in the report can be used to deny the claim. However, when you appeal the decision, you can be proactive by having your doctor provide clarifying statements and answer any inconsistencies the insurer might have flagged.
Find a Competent LTD Attorney Near Me
An LTD insurance claim denial is a huge setback, but you can overcome it through an administrative appeal. The appeal process is nuanced, so you need an attorney to increase the chances of a win. An attorney will even represent you in federal court when the internal appeal is unsuccessful.
At Leland Law, we understand the strategies insurers use to deny claims, the procedural conditions under ERISA statutes, and the need for a detailed administrative record, making us suitable to win the LTD benefits. Call us at 866-449-6476 to start California's initial claim or appeal process.
