Receiving the news that your long-term disability benefits were denied or terminated can be scary and overwhelming. Here are some things to be aware of to help reduce your stress and understand your denial letter.
Why Is Your Claim Being Denied?
Towards the beginning of most LTD denial letters, your insurance company will notify you of the basis of its decision. Some common reasons that an insurance company will deny LTD benefits include:
- There is insufficient clinical evidence to support your disability,
- There is a lack of objective evidence or abnormal findings to substantiate the severity of your condition,
- Your reported activities of daily living are inconsistent with your disability,
- Your symptoms have improved,
- Your medical treatment is not at the level that would be expected for a disabling condition,
- You are able to perform the duties of your occupation or another occupation that you may be qualified for,
- You failed to meet the elimination period,
- Your disability is based on a pre-existing condition that is excluded under the policy,
- There is a limitation on the period for which benefits will be paid because your disability is caused by a mental health condition,
- The onset of your disability occurred after your insurance coverage ended, and
- You failed to provide medical evidence or “proof of loss” within a specified timeframe.
Although these may sound like legitimate reasons to deny your claim, they often are not, so don’t be discouraged by what you read. You will have an opportunity to correct the record when you file your appeal.
How Do Insurers Support Their Denials?
Medical Reports
Much of the time, your insurance company relied on one or more medical consultants who reviewed your records and determined that you don’t have any restrictions or limitations that prevent you from returning to work. Your denial letter will rely on those consultants’ reports to support the insurance company’s reasons for denying your benefits. More often than not, your insurer’s consultants have ignored your supportive evidence and your treating physicians’ findings and instead focused on irrelevant, inaccurate, or selective information to minimize the severity of your symptoms.
Vocational Reports
Sometimes an insurer will also include in your denial letter the physical and cognitive responsibilities of your prior occupation or of an occupation that it thinks you can perform. And while the insurer may have employed a vocational consultant to determine these occupational demands, its list will likely look nothing like the work you used to do.
Policy Language
Each denial letter is required to include the policy provisions that your insurance company relied on when making its decision. The letter will quote the actual language from your policy, but it’s important to make sure you have a copy of your policy to confirm the accuracy of the language and to ensure that there isn’t any other plan language that is also applicable to your circumstances that your insurer has excluded from its letter. If you don’t have a copy of your policy, you should request a copy of it in writing from your prior employer.
What Recourse Do I Have?
Towards the end of your denial letter, your insurance company will notify you of your right to file an appeal and request your claim file. For example, you may see language similar to this:
Upon receipt of your written request, we’ll supply copies of documents, records and/or other relevant claim information. We’ll also supply a copy of our internal guidelines if they are relied on to make this decision.
If you don’t agree with our decision and/or calculations and want to file an appeal, you must send your reasons in writing and provide us with the documents requested earlier.
For instructions on how to file an appeal, please see the attached document.
Should you decide to file a written request for an appeal, we ask that you include the following information:
- Medical records or other information that supports your conclusion that our decision wasn’t correct.
- Other information necessary to support your appeal.
Requesting Your Claim File
Before filing an appeal, you want to make a written request to your insurance company for your complete claim file. Your claim file will include all of the information that your insurance company relied on when denying your benefits. This will include your medical and financial information, your insurer’s medical and vocational reviews, any surveillance or background reports, your insurer’s internal notes, and its communications with you, your prior employer, and your medical providers. Your request for your claim file:
- Should be made in writing,
- Should request your complete claim file and any information that your insurance company relied on when making its decision,
- Should request an electronic copy of your file (as opposed to a paper copy), and
- Should be made as soon as you receive your denial letter.
Submitting Your Appeal
An appeal is a written request for review of the denial of your benefits that is made to your insurer. Once you receive your claim file, you should seek the guidance of a disability attorney who can advise you on how to best appeal your insurance company’s decision. Depending on the basis of the denial, there is different information that you should submit with your appeal letter. For example:
- Additional medical records,
- Letters from your medical providers,
- Testing reports,
- Statements from your employer, friends, and family, and
- Caselaw and regulations supporting your claim.
How Long Do I Have to File an Appeal?
Towards the end of your denial letter, the insurer will notify you of how much time you have to file an appeal. It will look something like this:
If your claim is subject to the Employee Retirement Income Security Act (ERISA) of 1974 (“the Act”), you have the right to bring civil action under section 502(a) of the Act following an adverse benefit determination on review. Your failure to request a review within 180 days from the date of this letter may be a failure to exhaust the administrative remedies available under the Act and may affect your ability to bring a civil action under the Act.
Under most circumstances, the insurer will inform you that you have 180 days from receipt of your denial letter to submit your appeal. For most claims, if you do not file an appeal within 180 days, the insurance company’s decision will become final, and you will lose your right to file a lawsuit. 180 days can pass very quickly, so if you recently received a denial letter, you should contact our office as soon as possible so we can help you plan your next steps.