Applying for a long-term disability (LTD) claim can be a daunting process, especially when individuals are already dealing with the emotional and physical stress of a disabling condition.
Unfortunately, many LTD claims are rejected, leaving applicants frustrated and without the financial support they need. Understanding the common reasons behind these rejections can help individuals avoid common pitfalls and improve their chances of getting the benefits they deserve. Here are some of the most frequent reasons long-term disability claims are rejected:
1. Insufficient Medical Evidence
One of the most common reasons for the denial of an LTD claim is a lack of sufficient medical evidence. Insurers require thorough documentation to prove that the applicant’s condition truly limits their ability to work. Simply stating that you are in pain or unable to work isn’t enough. Detailed medical records, test results, physician’s notes, and a clear treatment history are essential. Claims are often rejected when there is a perceived gap in medical treatment, or when the insurance company deems the evidence provided to be insufficient to substantiate the disability.
2. Failure to Meet the Definition of Disability
Each insurance policy has its own definition of “disability,” which can vary significantly from one policy to another. In many cases, claims are denied because the applicant’s condition does not meet the insurer’s specific criteria for what constitutes a disability. For example, some policies may define disability as the inability to perform the tasks of your current occupation, while others require proof that you are unable to work in any occupation. This difference can be the key factor in determining whether a claim is accepted or rejected.
3. Missed Deadlines or Incorrect Paperwork
Filing a long-term disability claim involves several forms and deadlines. Claims are often rejected due to technical errors such as missing documents, incomplete forms, or failure to meet deadlines. Insurance companies can be very strict about the timeliness and accuracy of the paperwork, and even a minor error could lead to a denial. It’s essential to carefully follow all instructions and submit everything within the required time frame.
4. Inconsistent Medical Records
Consistency in your medical records is crucial when filing for LTD. If there is any discrepancy between what your doctor says and what you have reported to the insurance company, it could lead to a claim denial. Insurance adjusters are trained to spot inconsistencies, such as one report suggesting severe limitations while another indicates more minor issues. To avoid this, ensure that your medical records clearly and consistently reflect the true nature of your disability.
5. Lack of Follow-up on Treatment Plans
Insurance companies often deny claims if they believe the applicant is not following prescribed treatments. If your doctor has recommended a treatment plan, such as physical therapy, medication, or surgery, it’s essential to demonstrate that you are actively following it. Failure to do so can raise doubts about the severity of your condition or your willingness to recover, which could lead to a claim rejection.
6. Surveillance and Social Media Evidence
Insurers often conduct surveillance to assess whether the applicant’s behavior aligns with their claimed disability. They may also review social media accounts to look for evidence that contradicts the severity of the disability. For instance, if someone claims they cannot work due to chronic pain but is seen engaging in physical activities on social media, the insurance company may use this as grounds for denial. It’s important to be mindful of what is shared publicly and be aware that insurance companies may monitor your activity.
7. Pre-existing Conditions
Many LTD policies have exclusions for pre-existing conditions, meaning that if your disability is related to a condition you had before the coverage started, your claim could be denied. The insurance company will thoroughly review your medical history to determine if the condition that caused your disability was already present prior to the policy taking effect.
8. Independent Medical Examinations (IME) Discrepancies
Insurance companies often require claimants to undergo an independent medical examination (IME) by a doctor of their choice. If the findings of this examination differ from your treating physician’s diagnosis, the insurer may use this as a reason to reject your claim. These doctors are often seen as biased toward the insurance companies, so it’s important to be prepared and have your own doctor’s opinions well-documented.
9. Vocational Assessment Disagreements
Insurance companies may conduct a vocational assessment to determine whether you can perform any type of work, not just your current or previous job. If they conclude that you are capable of working in a different field or capacity, your claim may be denied. These assessments can be subjective, and disagreements between the vocational expert and your own statements about your limitations may lead to rejection.
Conclusion
While there are many reasons why long-term disability claims are rejected, being aware of these common pitfalls can help you avoid them. Ensuring that your medical documentation is thorough and consistent, adhering to your treatment plan, and being cautious about what you share publicly can significantly improve your chances of a successful claim. If your LTD claim is rejected, consulting a long-term disability claim lawyer can help you understand the reasons for the denial and assist you in the appeals process.
By being proactive and diligent, you can navigate the long-term disability claim process more effectively and improve your chances of securing the benefits you need.
Source: Affinity Law, Toronto
