Why Group Long-Term Disability Applications Get Denied
The benefits packages of American workers frequently include group coverage for long-term disability. If a worker sustains a disabling injury or develops a sickness that renders them unable to perform the important duties of their occupation, or in some cases, any occupation by which they are trained, educated, or suited, taking into consideration their station in life, these benefits kick in to help replace a percentage of their lost employment income after a waiting period.
It is no secret that a large segment of the American workforce is reaching the age at which disabilities become a serious threat to job and income security. Perhaps as a consequence, insurance companies that issue group long-term disability coverage are pushing back harder than ever on newly disabled workers’ claims for long-term group disability benefits.
In this blog post, we discuss some of the common reasons long-term group disability benefits applications get wrongfully denied, and how a skilled long-term group disability lawyer can really help you.
One Claim, Lots of Possible Reasons for Denial
Long-term group disability is a form of insurance. Like any insurance policy, it is crucial you understand the features, advantages and benefits before you file your claim. Insurance companies do not stay in business by paying every claim that comes along. Instead, they hold beneficiaries—in this case, you—to strict claims procedures and requirements in hopes of having an excuse, any excuse, for wrongfully denying a claim. Fortunately, by Federal law, claims denials must explain those excuses in writing.
Let’s look at a few of the common reasons long-term group disability plans give for denying a valid claim for long-term group disability benefits.
Failure to Meet Plan Disability Qualifications
Most employer-provided long-term disability plans are governed by a federal law known as the Employee Retirement Income Security Act, or ERISA. ERISA sets minimum standards for employer-provided disability plans, including strict timeframes and procedures for applying for benefits and filing an administrative appeal of wrongful claims denials.
One aspect of group long-term disability plans that ERISA does not dictate, however, is what it means to be disabled. As a general matter, plans tend to define disability as a sickness or accident that prevents a worker from reliably performing the important duties of your occupation with reasonable continuity and in the usual and customary way.
Some plans treat a worker as disabled if he or she cannot perform the important duties of a specific occupation. Others call a worker disabled only when he or she cannot perform the important duties of any occupation by which you are trained, educated, or suited, taking into consideration your station in life. Most plans use a “national economy” standard to determine generic occupational duties rather than the workers specific tasks of the job.
Many arbitrary and capricious bad-faith claim denials rely on language in the plan documents to argue that you are not disabled within the definition of the plan. That is why, before filing an initial claim for benefits, you must review carefully the plan’s definition of disability to ensure your claim fits within its (often-narrow) parameters. An experienced group long-term disability insurance lawyer can help you do this.
Lack of Medical Documentation
You cannot expect to receive long-term disability benefits without sending proper and most persuasive medical evidence to the plan administrator. No plan will approve a claim on your say-so or in some cases based on your self reported claims of pain or fatigue.
The trick, however, is figuring out all of the proper objective and subjective medical evidence you need to submit. Typically, a well-supported claim will include witness affidavits, accident reports, your treating physician’s chart notes, updated complete medical records and testing, pharmacy records, and your treating doctor’s detailed opinion on why you are unable to perform the important duties of your occupation despite your care and treatment.
To avoid denial of a long-term disability claim for lack of sufficient medical documentation, obtain and review all of your relevant medical records from your treating doctor, physical therapist, or therapist. An experienced long-term group disability attorney can help you determine which of those records to submit, and what other proper medical evidence you may need to request from your doctor to support your claim.
Procedural Missteps
All plans, and especially employer-provided plans covered by ERISA, contain strict and unforgiving deadlines and time-specific filings you and the plan administrator must follow when submitting, evaluating, and disputing a claim for long-term group disability benefits. Long-term group disability plans will often deny claims because the applicant has not followed the mandated procedures, or has missed strict and unforgiving deadlines.
The best way to avoid the wrongful delay or denial of a disability benefits claim on procedural grounds is not to make procedural errors in the first place. You can protect yourself against these errors by reading your plan language closely with a long-term group disability insurance lawyer to ensure you follow every step and don’t make any fatal claim errors or mistakes.
Investigations
Some plan administrators will evaluate long-term disability benefit claims by sending investigators to conduct video surveillance of the claimants’ lives and daily activities. This is a tactic they can easily abuse by capturing images or video of claimants at moments when they look healthy, and mining claimants’ social media feeds for evidence that seems inconsistent with a claim.
To avoid a wrongful denial on this basis, claimants should always be truthful in their claim applications, of course, and follow a medical plan of treatment. If you feel a claim was wrongfully denied because of a misguided investigation, an experienced long-term group disability insurance attorney can help you evaluate whether the plan has engaged in wrongful, and perhaps even illegal, claim conduct.
How a Long-Term Group Disability Lawyer Can Help
Filing a claim for long-term disability benefits is a complicated process. Plan administrators try to make submitting a claim seem easy and straightforward, but that is frequently not an accurate reflection of the pitfalls that await claimants who do not understand the ins and outs of how plan administrators evaluate and deny disability claim applications arbitrarily.
The absolute best defense against a claim denial, in our experience, is to retain an experienced ERISA attorney to help you prepare your group long-term disability benefits claim in the first place. Most workers do not have the time, energy, or legal expertise to read and truly understand the detailed language contained in a benefits plan. Nor do they have much, if any, understanding of ERISA and its accompanying regulations or tricky filing deadlines.
Do not wait for your claim to face a wrongful denial before speaking with an experienced group long-term disability insurance attorney. Experienced group ERISA lawyers know how to craft a long-term group disability benefits claim application that fits within the language of the plan and the law. They can minimize the possibility that a plan administrator will find a technical reason to deny your claim in bad faith or arbitrarily.
If you had an injury or suffered a sickness that left you unable to reliably perform the important duties of your occupation, and you want to file a claim application for long-term group disability benefits, contact an experienced California disability attorney to help guide you from day one.