Why Was My Long-Term Disability Claim Denied?

Applying for long-term disability (LTD) benefits can be a lifeline when a serious illness or injury prevents you from working. These benefits are designed to replace a portion of your income, providing financial stability during a difficult time. However, many people are shocked and disheartened when their initial claim is denied.

One of the most frequent reasons for an LTD claim denial is the lack of objective and sufficient medical evidence. It’s not enough to simply state that you are unable to work; your insurance provider requires comprehensive medical documentation to support your claim.

A denial letter might state that your medical records do not adequately prove the severity of your condition or its impact on your ability to perform your job duties. This can happen for several reasons:

• Incomplete Records: Your file may be missing reports from specialists, crucial test results (like MRIs, X-rays, or blood tests), or notes from physical therapy sessions.
• Vague Physician Statements: Your doctor might support your claim but fail to provide detailed, objective findings. A note that says “patient is disabled” is not as compelling as one that details specific functional limitations, such as the inability to sit for more than 15 minutes or lift more than 10 pounds.
• Infrequent Medical Treatment: Insurance companies often interpret gaps in treatment as a sign that your condition is not severe or has improved. It is crucial to maintain regular appointments with your healthcare providers and follow their recommended treatment plans.

To avoid this pitfall, work closely with your doctors to ensure they understand the type of information the insurance company needs. Provide them with a copy of your job description so they can make a direct connection between your medical limitations and your work responsibilities.

Every LTD policy has a specific definition of “disability,” and failing to meet this definition is a common cause for denial. These definitions can be complex and often change after a certain period, typically 24 months.

Initially, most policies define disability as the inability to perform the material duties of your own occupation. This means you are considered disabled if you cannot do the job you held before your illness or injury.

However, after 24 months, the definition often shifts to the inability to perform any occupation for which you are reasonably suited by education, training, or experience. This is a much stricter standard to meet. An insurer might deny your claim by arguing that even if you can’t return to your old job, you could work in a less demanding role, such as a sedentary desk job.

Insurers often draw a line between conditions with objective evidence (like a broken bone visible on an X-ray) and those based on subjective symptoms (like pain, fatigue, or mental health issues). Claims for conditions like fibromyalgia, chronic fatigue syndrome, and depression are frequently denied because insurers argue there is no “objective” proof of the disability.

Many LTD policies include a “pre-existing condition exclusion” clause. This provision allows the insurer to deny a claim if it relates to a condition for which you received medical treatment or advice shortly before your coverage began.

Typically, this exclusion applies to any condition treated within a “look-back” period, which is often 3 to 12 months before your policy’s effective date. If you then file a claim within the first 12 to 24 months of being covered, the insurance company will scrutinize your medical history for any related pre-existing conditions. For example, if you saw a doctor for back pain a month before your coverage started and later file an LTD claim for a herniated disc, the insurer might deny it based on this exclusion.

LTD policies are legal contracts with strict deadlines and procedures. Failing to follow these rules can lead to a “technical denial,” even if your medical condition is severe. Common procedural missteps include:

• Missing Deadlines: Policies have firm deadlines for filing an initial claim and for appealing a denial. Missing these dates can result in a permanent loss of your right to benefits.
• Incomplete Forms: Application and appeal forms can be lengthy and complex. Leaving sections blank or providing incomplete information can cause delays and denials.
• Not Cooperating: Your policy likely requires you to cooperate with the insurance company. This includes attending an Independent Medical Examination (IME) if requested. An IME is an examination by a doctor chosen by the insurer. Failure to attend can be grounds for denial.

Insurance companies sometimes hire private investigators to conduct surveillance on claimants. An investigator might film you doing daily activities like grocery shopping, driving, or walking your dog. The insurer may then use this footage to argue that your activities are inconsistent with your reported limitations.

For instance, a 30-second video of you lifting a bag of groceries might be used to contradict your doctor’s note stating you cannot lift more than 10 pounds. While you may have been in severe pain afterward, the video doesn’t show that part. Insurers can take these activities out of context to build a case against you. Similarly, they will scour your social media accounts for photos or posts that conflict with your claim.

While receiving a denial can be discouraging, it is not the end of the road. You have the right to appeal. To build a stronger case, consider the following steps:

1. Request Your Claim File: The insurance company is required to provide you with a complete copy of your claim file, which includes all medical records, internal notes, and reports they used to make their decision.
2. Obtain Additional Medical Evidence: Work with your doctor to get a detailed narrative report that outlines your diagnosis, prognosis, and specific functional limitations. Consider getting a Functional Capacity Evaluation (FCE), which is a comprehensive set of tests designed to objectively measure your physical abilities.
3. Get Vocational Evidence: A vocational expert can assess your skills and experience to provide an opinion on whether you can perform any occupation, which is crucial for claims under the “any occupation” standard.
4. Write a Personal Statement: Describe in your own words how your condition affects your daily life and your ability to work.

Navigating this process can be difficult, especially when you are managing a health condition. If you need help with social security claims in Salt Lake City, seeking professional guidance can make a significant difference in the outcome of your case.

Understanding why LTD claims are denied is the first step toward securing the benefits you need. By ensuring your claim is supported by strong medical evidence and that you have met all policy requirements, you can significantly improve your chances of approval.