If you work for an employer that provides you with long term disability (LTD) coverage governed by the Employee Retirement Income Security Act (ERISA), you should be able to expect that you will receive the benefits you need if you become disabled and properly file a claim in accordance with ERISA claims procedures. However, your application for benefits will be reviewed by a claims administrator who is likely working for the insurance provider. Like any other type of insurance company, LTD providers are trying to minimize liability whenever possible and, for this reason, claims administrators will deny claims on a regular basis for many different reasons–some valid and some not.
While it is possible–and advisable–to appeal a denial, the ERISA appeals process can be complex, and it is imperative to understand the reason behind your denial in order to present the strongest case possible on appeal. The following are some of the common reasons for long term disability claim denials.
Your condition does not qualify as a “disability” under your policy — Each policy will define what constitutes a disability. Two common definitions include:
Some claims will also specifically exclude certain conditions from coverage. If the claims administrator does not believe your disability qualifies under your particular plan, you may receive a denial.
There was not sufficient evidence of your condition — Medical records are key to proving that you, in fact, have a serious condition that renders you disabled, as the insurance company will want evidence that you are seeking regular medical treatment for your condition. In addition, you should provide a statement from your doctor regarding the extent of your disability. If the insurer fails to obtain all of the necessary medical records, if you fail to include a doctor’s statement, or if you have not been seeking adequate treatment, you could get denied.
Investigators determine you are not disabled — During the claims process, many insurers will have investigators taking video footage of your daily activities. If the video shows you engaging in behaviors that are inconsistent with the disability and limitations that you claim, it can result in a denial.
While receiving an LTD benefits denial can be disheartening, there are actions you can and should take to preserve your rights to the benefits you deserve under ERISA. You have an extremely limited time in which to appeal the denial, however, so you should not delay in contacting a Chicago long term disability lawyer who fully understands the ERISA appeals process. In addition, consulting with an LTD attorney prior to applying for benefits can help to ensure you include all of the necessary information and medical evidence needed for a sufficient finding of disability and approval of your claim. In either situation, Bartolic Law is here to help. We focus on ERISA claims, so please call us at 312-646-4366 for a free consultation.