Why Do Insurers Deny Long-Term Disability Claims?
Insurers deny claims for a variety of reasons. It could be because they failed to receive the documents needed to make the decision within the regulatory timeframe. It may be because you failed to cooperate with them, like not attending a scheduled exam. It might be because the evidence does not support your claim or your condition is excluded from coverage under the policy. It may also be that they simply don’t want to pay. They might have recognized that your case will cost hundreds of thousands of dollars, so they deny or terminate your claim and force you to settle for pennies on the dollar.
What Is “Own Occupation” Versus “Any Occupation” Under ERISA?
Most ERISA policies have two definitions of disability. For the first 24 months, you are considered disabled, if you are unable to perform your own occupation. After that, you are disabled, if you cannot perform any occupation. Your own occupation, for ERISA purposes, refers to the class of work that you performed before you stopped working. It is not necessarily the job that you were doing. Being a registered nurse is an occupation; working as an emergency room registered nurse is a job. While you might not have the ability to perform the physical demands of an emergency room nurse that does not mean that you can no longer perform your occupation as a Registered Nurse in an office setting or as a nurse case manager.
If I Failed To Disclose Pre-Existing Injuries On My Application Or Failed To Provide Employment And / Or Income History And Was Denied Long Term Disability, Can I Simply Modify My Application?
If you are denied long-term disability benefits, you have an opportunity to appeal the denial under ERISA. You can provide evidence in support of your appeal, which may include reasons why you failed to disclose relevant information. If you are already denied, simply amending or modifying the application will not resolve the issue; an appeal is required.
What Conditions May Not Be Covered Under A Long-Term Disability Policy?
Exclusions and limitations are policy specific. Some policies exclude coverage of pre-existing conditions, if you were examined, treated or took medications for that condition within a certain time period of obtaining coverage. Other policies limit coverage for mental health, alcohol related conditions, or non medical conditions such as being incarcerated.
Is It True That Most Long-Term Policies Pay Benefits For Only a Limited Number Of Months For Certain Conditions And Disabilities Caused By Mental Illnesses?
Most ERISA policies have a limited pay provision for disabilities caused by mental health condition. If however, an organic problem, such as Dementia or Alzheimer causes the mental health impairment some policies will exclude those from the mental health limitations.
If I Am Close To Retirement Age On My Date Of Disability, Will I Receive Lifelong Disability Benefits?
Each policy dictates the maximum benefit period. Most ERISA policies pay until age 65 or until social security normal retirement age (SSNRA).
If My Doctor Fails To Provide The Insurance Company With Claim Forms Or Requested Information On Time, Is It Possible To Explain This And Push My Application Through To Approval?
Without the supporting medical information, your insurance company will likely deny your claim. While it is possible to get your claim approved without your doctor’s cooperation, it is extremely difficult. Most policies provided the insurance company the right to examine you. However, often the insurance companies only send you to an exam when they wish to deny your claim. If your doctor is unwilling or unable to assist with your claim, you might need to get an independent evaluation.
The Insurance Company Has Accused Me Of Not Providing Enough Objective Evidence of My Medical Condition. What Does That Mean?
Objective evidence is something that can be observed by diagnostic testing or study, such as an X-ray or MRI. There are some medical conditions that are not suitable to objective evidence in the traditional sense, such as fibromyalgia, chronic pain syndrome, and mental health conditions. Diagnosis and treatment for those conditions rely on your self-reporting and your physician’s clinical examination. Some courts will accept positive tender points in specific locations, along with other symptoms, as objective evidence of fibromyalgia. Depending on the nature of your mental health condition, a neuro-psychological evaluation might be necessary to provide the objective evidence of the impairment. For physical conditions, a functional capacity evaluation might be beneficial in providing the objective evidence needed.
How Do Insurers Use Surveillance In An Effort To Prove That In Am Not Disabled?
The main reason for insurers verifying your activities is to see whether the activities are consistent with the information you provided them, or the restrictions and limitations prescribed by your physician. The insurance company can conduct standard surveillance, where they follow you and take video of you performing various activities to see whether your activities are consistent with your restrictions and limitations or your statements on the forms completed for them.
They can monitor not only your physical activity, but your online activity as well. We call that electronic surveillance. If you have a post on Facebook, Twitter, Instagram, or TikTok, it is in the public sphere and is fair game. If the activities depicted in you are postings are inconsistent with the nature of your medical condition, or your restrictions and limitations they can use that as a basis to terminate your claim.
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