Tips on Long-Term Disability Claims & ERISA

Tips on Long-Term Disability Claims & ERISA

Life can be unpredictable. Many of us find comfort in having backup plans and safety nets for our lives. People open a savings account for unexpected expenses, families own two vehicles should one break down, and many employees carry long-term disability (LTD) insurance through their employer in case they get hurt and are unable to work.

Employer-provided LTD policies are governed by a federal law known as ERISA, the Employee Retirement Income Security Act. LTD applications are reviewed by a claim administrator, and these claim administrators work for the insurance company. There is an obvious conflict of interest, and therefore, claims are often denied. Claim administrators may feel pressured to deny claims, even deserving ones, so the insurance company they work for saves money. Getting an LTD claim approved is a complicated process. Here are some common reasons for these claims being denied, as well as mistakes to avoid during the process.

Missing the deadline.

Most employer-provided insurance plans give 180 days to appeal an initial denial. Look for the deadline on the notice of denial. It is recommended to use this time frame to talk to an LTD attorney who can gather evidence and complete the required documents. The evidence and documents are submitted to the insurance company and are contained in the “administrative record” for your case.

The administrative record is something that must be requested from the insurance company. This record has all the information about why your claim was denied, as well as the medical reports from doctors. Knowing exactly why your claim was denied will help your attorney know how to defend you.

Additionally, if your claim goes through all the administrative appeal channels without being approved, the claim could go all the way to federal court. Only the information in the administrative record is what will be considered when deciding your case. This is part of ERISA law. You can not wait until court to present records and/or provider statements, as they will not be taken into account. They must be added to the administrative record first.

Providing inadequate medical evidence.

When involved in an LTD claim, you must go to regular medical appointments. The insurance company expects you to make the necessary visits to your doctor or specialists. You should not miss any appointments, or it could be used against you as evidence that you are not disabled.

Your claim could be denied because the insurance company does not have the appropriate medical records. Though it may be the insurance company’s fault for not requesting them, you or your attorney will need to follow up and ask for the records they, and then double check to make sure no records are missing.

One of the most crucial elements in proving your disability is your doctor’s opinion and statement. If your doctor is willing to write a detailed letter supporting your disability and stating what your limitations are, it will go a long way in helping to win your claim.

It is also important to get reports from experts, which could include a functional capacity evaluation report and a vocational expert report. A functional capacity report is an objective test performed by a physical therapist. You will be tested for various job-related tasks like sitting, standing, pushing, pulling, and lifting. A vocational expert is someone who knows about availability in the job market and what skills are needed to perform specific jobs. Your insurance company will likely have their own vocational expert write a report, which will likely lean in favor of the insurance company. You or your attorney may need to find a vocational expert of your own to help with your claim.

Failure to meet the policy’s definition of disabled.

Be sure to check your LTD policy summary and find its definition of disability. It will typically define disability one of two ways. It will either define disability as being medically unable to carry out the duties of your “own occupation,” or  as the inability to perform the duties of “any occupation.” There is a big difference between the two. If you are an injured construction worker applying for LTD, and your policy defines disability under the description of “any occupation,” then you may still be expected to go out and find a job.

Your insurance company is allowed to ask investigators to follow you and take video surveillance. If they record you doing anything a disabled person should not be able to, your claim could get denied, or if you are already receiving benefits, they could be canceled.

For example, if you suffer from chronic back pain, you likely have good days and bad days. Most likely, your good days aren’t pain-free, but you may have enough energy to go out and try to do light gardening or landscaping around your house. If the investigator should catch you on this good day and take footage of you performing this work, it might be enough to justify a denial. The best advice is to simply follow your doctor’s restrictions at all times.  

Talk with a long-term disability attorney.

If your initial long-term disability application has been denied, consult with an attorney, as that is the best way to increase your chance of obtaining approval. A long-term disability lawyer, such as Ethan Vessels, is familiar with the rules and know how the insurance companies operate.

Often, when people try to handle the appeals process on their own, important information can get left out of the appeal. This really plays to the advantage of the insurance company. As stated earlier, if evidence is not submitted in the administrative record during the internal appeals process, it cannot be used later in court.

Contact Fields, Dehmlow & Vessels, LLC to speak with Ethan Vessels, an experienced long-term disability attorney. Call us at 740-374-5346 or fill out our online contact form.