Scales of justice with a gavel in front of it

Has Your Long Term Disability Claim Been Denied?

It is an awful realization to discover the rejection of your long-term disability (LTD) claim. The very purpose of LTD insurance is to protect you financially when you need it because you can’t work due to an illness, injury or accident. If you’re in the process of determining whether to dispute the denial, consider some of the common reasons LTD claims are denied. With the legal assistance of a disability lawyer in Owen Sound, several disputes about your benefits can be resolved.


Error(s) In Submitting the Claim


Many LTD claims are unfortunately rejected due to errors you may have made related to your LTD application, such as clerical or procedural errors or missing the deadline to submit the claim. Sometimes you can resubmit the claim with the corrections and get your claim approved. If you were late in submitting or resubmitting the claim, it might be accepted if you have a valid reason for the delay. A LTD lawyer who oversees your claim will ensure you don’t miss critical deadlines.

Insufficient Evidence of Your Disability


Insufficient evidence is a frequently sited reason why an LTD claim is denied. If you or your doctor fail to precisely describe how the injury or illness impacts your daily activities with wording that the insurer can verify according to their guidelines, your claim could be denied. Or, you might need to give supporting evidence (e.g. test results) for your doctor’s diagnosis. If your insurer does request “objective evidence,” you will want to have your lawyer review the contract to ensure the policy contains this requirement. It is only when the insurer has sufficient evidence about your disability that they will decide whether your situation meets the definition to approve the claim.

Failing to Meet the Disability Definition


Probably the most common reason for being refused LTD benefits is failing to meet the disability definition. Two definitions of disability apply in most disability policies. The first definition, which allows coverage for short-term disability benefits, normally requires you to be medically unable to work at your own occupation, and typically only applies for the first two years of your disability. The second definition, which extends income protection for a longer-term beyond the initial first two year period, usually requires you to be medically unable to perform the essential duties of any occupation for which you are reasonably qualified by training, education or experience. When an employer is willing to provide accommodations and shorter hours, your insurer may not believe that you cannot conduct any reasonable work available to you.

Policy Exclusions


Another reason for denial of a LTD claim is a policy exclusion. Most frequently, the exclusion is related to the illness itself or the reason for the illness, such as a condition that pre-existed before the disability insurance came into effect. A pre-existing injury or illness is one that a physician was consulted for or for which medication or other treatment was prescribed. If there was a prior injury from a personal injury accident, for example, it is assumed that you were already adequately compensated for your losses, including your future losses at that time. Or, if the illness was self-imposed, such as liver failure related to alcoholism, there could be an exclusion. It is best to have an LTD lawyer review the policy terms to advise you.

Fortunately, sometimes a policy does not explicitly exclude pre-existing conditions and instead entails language about coverage for an unexpected reoccurrence or aggravation of a condition. In this situation, you would need to make a case for why the change was unexpected. For example, a new factor may have caused the same condition to occur (e.g., a different cause of your depression) or a new factor worsened the condition (e.g., difficulty getting access to medical care while abroad), in which case you might have a case to dispute the LTD claim denial.

Assessment and/or Treatment Compliance


Demonstrating that you are making efforts to assist in your recovery is critical for you to receive LTD benefits. You are required to follow the treatment recommendations you have received from your doctor or rehabilitation specialist for your condition. If a treatment is not working, then you must to discuss this with your doctor instead of discontinuing treatment as your own decision. Additionally, you must comply with any assessment requirements, such as undergoing an independent medical exam if the insurer asks to you attend one.

Failing to Meet Contractual Requirements


Failing to meet the contractual requirements is also a possible reason for rejection or early termination of benefits. For example, your LTD coverage could terminate when you reach age 65. Or, you may not be entitled to disability benefits at all if you have not met the eligibility period as an employee or the minimum hours of work to qualify or if your claim is not legitimate.

Contrary Evidence


If there is any contradictory evidence for your LTD claim (e.g., exaggerating injuries, misrepresentation on the application), your credibility may be undermined and your claim immediately terminated. You might also be asked to repay any benefits received.

Evidence that could be deemed contradictory includes an “independent” medical examiner’s report stating they believe you can work at least partially. Any video surveillance of your public activities by a private investigator could be used as evidence by your insurer. More recently, social media posts, including Facebook, Twitter and Instagram are being studied more frequently for any inconsistencies. For example, your reputation may be under attack if you claim to have back pain and regularly lie at home depressed but then upload photos about a sports event you were thrilled to participate in - even if this isn’t quite a contradiction.

Speak to a Disability Lawyer in Owen Sound to Find Out What You Can Do


Contact Tamming Law for a consultation about disputing your denied claim and getting it paid if you disagree with the reason provided by the insurer. The Owen Sound lawyers at our firm can assist you with your LTD insurance dispute. We have substantial knowledge and experience of the insurance statutes and recent cases. We may be able to resolve your claim quickly. For more information about denied LTD benefits, read this blog or contact the Tamming Law disability lawyers in Owen Sound at 519-371-8999.