If you’re injured or suffering from a serious medical condition that stops you from working, you need long-term disability insurance for financial support. However, getting approval for your claim isn’t guaranteed.
This insurance is often provided by employers in group plans or bought individually from an insurance company.
It’s common for insurance companies to delay benefits in an effort to keep the money from the premiums.
Since claims can be denied for many reasons, it’s important to understand why your claim might be rejected before you submit it.
Below are some of the most common reasons an insurance company might deny a long-term disability claim.
If you’re suffering from a disabling condition, you may still qualify for disability benefits. However, a Social Security attorney in Orlando can help you explore your options and ensure your claim is properly handled.
Injury or medical condition might not meet the insurance policy’s definition of “disability.”
Each long-term disability insurance policy has its own rules and definitions for what qualifies as a “disability.” For example, under an “own occupation” definition, you’re considered disabled if you can’t do your specific job.
Under an “any occupation” definition, you’re considered disabled if you can’t do any job at all.
It’s important to know that some policies switch from “own occupation” to “any occupation” after a certain period, like two years.
Insufficient Medical Evidence and Documentation
When you file a disability claim, it needs to be backed by written proof of your condition. Sometimes, the insurance company may not gather all of your medical records.
Make sure they request all the necessary documents, including medical records, doctor’s notes, prescriptions, and test results like X-rays, MRIs, and lab tests.
Also, you’ll need to show you’re getting regular treatment from a doctor or therapist. If you have a mental disorder, you must show you’re seeing a psychologist or psychiatrist. Without this evidence, your claim might be denied.
Missing Doctor’s Statement
One of the most important pieces of evidence is a doctor’s report about your condition, explaining your limitations and how they affect your ability to work.
Don’t just use the forms the insurance company provides—ask your doctor to write a detailed letter and submit it.
If your doctor refuses, it may be necessary to find another one who can provide the statement you need.
The Condition Is Not Covered by the Policy
Not all conditions are covered by long-term disability plans. Some policies won’t cover issues like drug or alcohol abuse, self-inflicted injuries, or injuries related to a crime.
Pre-existing conditions (conditions you had treatment for or symptoms of before applying for the policy) are often excluded.
For example, if you had medical treatment or symptoms within a certain time before your policy started, you may not be covered.
Also, some conditions like depression, fibromyalgia, and chronic fatigue syndrome may be limited or denied because they are based on subjective symptoms.
Independent Medical Examiner Disputes Disability
If the insurance company has doubts about whether your condition qualifies as disabling, they may require you to undergo an Independent Medical Exam (IME).
The insurance company will choose the doctor for this exam, often one who has been favorable to them in the past.
This doctor might not have the proper training or specialization to properly assess your condition, and they might not even receive your full medical records.
As a result, the doctor may conclude that your condition isn’t disabling, which is what the insurer is hoping for.
Missed Deadlines
Meeting all deadlines for filing your claim and submitting documents is crucial. If your claim is denied, make sure you note all filing and appeal deadlines. You have 180 days to make an appeal for an initial denial.
If you miss this deadline, you won’t be able to sue the insurer that too in federal court. It’s also important to submit all medical records and documentation as soon as possible.
In that case, taking help from a Social Security lawyer in Orlando can be a wise choice.
Federal courts can only review the administrative record, which includes all the documents the insurer has used to make its decision.
Once a lawsuit is filed, the court can only consider the evidence that’s already in the administrative record, meaning new evidence is typically not allowed.