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Top Five Reasons for Long-Term Disability Denials

You have suffered injuries or developed a serious medical condition that makes you unable to work. Fortunately, your employer sponsors a long-term disability plan. You have paid your premiums every month, as they were dutifully taken from your paychecks. So, you do what anyone would do: You call and file your claim. For most applicants, this experience is fairly routine and results in an award of benefits. Sadly, however, there is an increasing tendency for insurance companies to deny these rightful disability claims. If this has happened to you, then the experienced long-term disability lawyers of Burke Harvey, LLC are here to help. Here are five of the most common reasons for denials.

  1. Lack of Medical Evidence

Many people applying for long-term disability do not realize how thoroughly their medical history will be analyzed. A good example may be a rotator cuff injury to the shoulder. Perhaps you have worked in a manual labor job for years and now you are suffering from a painful injury that limits your ability to work. You know you will have to undergo surgery to fix the problem, so you go to your doctor, get the routine tests and receive a diagnosis.

This does not automatically mean your claim will be approved. It is important that each diagnostic test be provided to the insurance company at the right time. Failure to obtain the right diagnosis, diagnostics or treatment could be a problem.

  • Technical Deadlines and Procedural Rules

There are also deadlines and procedural rules that must be carefully followed. This usually becomes a problem when people have disability insurance through an ERISA plan. The Employee Retirement Income Security Act of 1974 (“ERISA”) is a federal statute that governs large employer health plans, including disability plans provided through employer cafeteria plans. When a plan is governed by ERISA, you will have strict deadlines on filing your claim for benefits and appealing a denial.

If your claim is initially denied, you must exhaust all administrative remedies through ERISA. You have just 180 days to file your appeal. If you fail to do so, you lose your right to file a civil lawsuit. Therefore, it is very important to talk to a long-term disability lawyer immediately upon a denial. 

  • Negative Evidence Against Claimant

Sometimes claims are denied because of evidence that may conflict with your account of your disability. For instance, perhaps a doctor put something in his report stating that you are still able to work, even though you are not. Or maybe your claim file includes forms that leave open the issue of whether your injury or condition is permanent or temporary in nature.

Negative claims information can and usually will be interpreted against you in order to deny your claim. The insurance company’s goal is to avoid paying or minimize the number of claims they must pay. This is how they make money.

  • Not Meeting Policy Terms

Each long-term disability insurance plan has its own policy contract. This important contractual document will include numerous terms and definitions that dictate what you must do in order to preserve your rights. If you fail to meet certain terms, you could face an unfair denial based on the insurance company claiming you breached your contract or failed to meet certain terms that trigger coverage.

Here are some examples of policy terms with which you may need to comply:

  • Use proper forms
  • Meet deadlines
  • Notice requirements
  • Approved testing or diagnostics
  • Insurance Bad Faith

Finally, there are times when your claim was properly filed and you did everything correctly, but for some reason, the insurance company still denies your claim. You met the deadline and you provided the insurance company access to your health information, yet they denied you with either a contrived explanation or no explanation at all. In some cases, insurance companies may delay so long that by the time the claim is approved, the damage is done. In these types of situations, it is possible that your insurance carrier has acted in “bad faith.” This means the insurance company has breached its contract in such a willful or careless way that a court could award you compensation for the insurance company’s actions.

Getting Help with Bad Faith Insurance Cases

If you suspect your insurance company is deploying bad faith tactics in denying your claim, call Burke Harvey, LLC, today. Our attorneys have years of experience fighting against nasty and unfair insurance tactics. Call or visit us online today to learn more and to schedule a free consultation.