Ortiz Law Firm is dedicated to helping people recover the disability benefits they deserve. We handle group Long Term Disability (LTD) claims, individual disability insurance policy claims, ERISA disability claims, and Social Security Disability claims.

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Who Decides If I’m Disabled In A Long-Term Disability Insurance Claim?

You might assume that a doctor or an independent reviewer decides your disability status. However, in almost all long-term disability insurance cases, the insurance adjuster is the gatekeeper between you and your benefits. Their job is to review your case, check medical records, and decide claims based on the applicable policy.

The Role of the Insurance Adjuster

Insurance adjusters assess your claim by examining medical records, doctors’ notes, and sometimes even interviewing claimants. They look for consistency in your medical history and validate your condition against the policy’s definition of disability to decide if you really meet the criteria set by your insurance policy.

Most adjusters aren’t lawyers or medical experts. They lack the specialized training needed to thoroughly review medical evidence. While they may consult with their own hired experts to get an opinion on what you can and cannot do, it’s ultimately the adjuster’s decision.

Conflict of Interest

One key issue with this is a conflict of interest. Since insurance adjusters work for the insurance company, there might be an incentive to deny or limit claims to save money. This potential conflict can sometimes make the process feel unfair.

Imagine someone grading their own homework. They might be tempted to overlook mistakes. Similarly, insurance adjusters might face pressure to act in the company’s favor rather than yours. This can lead to denied claims or reduced benefits. In some situations, it might be necessary to appeal their decision or file a lawsuit.

RELATED VIDEO: Who Decides If I Am Disabled In A Long-Term Disability Claim?

Key Entities Involved in Determining Disability

When your insurance adjuster is deciding if you’re disabled for a long-term disability claim, several key entities play an important role. A combination of reports from medical professionals, IMEs, and vocational experts are used to decide your claim. Each one adds a piece to the puzzle, helping to paint a complete picture of your ability to work.

Medical Professionals

Medical professionals are often the first to evaluate your condition. Their evaluations and reports have an enormous impact on your disability claim. Your doctors, specialists, and therapists provide detailed medical records, diagnosis, and treatment plans.

These professionals:

  • Conduct Thorough Examinations: They examine you, run tests, and diagnose your condition.
  • Create Medical Reports: They write detailed reports that describe your limitations, symptoms, and treatments.
  • Follow Up and Monitor: They continue to track your progress and adjust your treatment as needed.

Without their expert input, insurance companies would have a hard time understanding the true extent of your disability. Your treating doctor’s opinion is a cornerstone in determining your eligibility for benefits.

Independent Medical Examiners

Insurance companies often order independent medical exams (IMEs) to get an unbiased look at your condition. Third-party doctors who don’t have a history with you perform these exams. Insurance companies hire these doctors to give a fresh perspective and ensure that the assessment is impartial.

These examiners:

  • Perform Specific Evaluations: They focus on specific aspects of your health related to your claim.
  • Write Independent Reports: They create reports that the insurance company uses alongside your regular medical records.

However, these exams are anything but independent. Insurance companies repeatedly hire the same doctors because they know these doctors are more likely to side with the insurance company. Many IME reports contradict the findings of the treating provider.

Vocational Experts

Vocational experts assess your ability to work. Unlike doctors, they aren’t assessing your medical condition, but how your condition affects your ability to perform job tasks.

A vocational expert will:

  • Evaluate Job Skills: They look at your skills, education, and work history.
  • Assess Work Capability: They determine if you can do your current job or any other job.
  • Provide Vocational Reports: They write reports that help to decide if your disability prevents you from working.

Vocational experts are crucial because even if a medical condition is severe, it might not be disabling if you can still perform some type of work. These experts help complete the picture by showing how your medical limitations translate into the job market.

In many claims, the combination of reports from medical professionals, IMEs, and vocational experts creates a comprehensive view of your disability. Each entity’s input helps to ensure a fair and thorough evaluation of your claim.

Criteria for Disability Determination

When filing for long-term disability, understanding the criteria for disability determination is key. This process involves evaluating various elements to decide if you qualify for benefits. Let’s break down what’s involved.

The Definition of Disability

The definition of disability can vary depending on your insurance policy. The definition of disability requires that you cannot perform the duties of your own occupation or any occupation.

  • Own Occupation: This means you can’t perform one, some, or all of the major tasks of the job you were doing before you became disabled. You must look to the wording of your individual policy.
  • Any Occupation: This is a stricter definition. It means you can’t do any job for which you are reasonably qualified by education, training, or experience. Although some policies may have an income threshold that still must be satisfied.

Your policy will specify which definition applies. Knowing this helps you understand what you need to prove.

Medical Evidence and Documentation

Medical evidence is crucial in proving your disability. This evidence comes from your healthcare providers and includes a variety of documents.

  • Doctor’s Notes: Regularly updated notes that detail your symptoms and treatment.
  • Diagnostic Tests: MRI scans, X-rays, and blood tests can provide concrete proof of your condition.
  • Treatment Records: Documents that show the treatments you’ve undergone, medications your doctors have prescribed, and their effectiveness.

Thorough documentation strengthens your claim. It shows a complete history of your condition and how it affects your daily life.

Vocational Assessments

Vocational assessments evaluate your ability to work. These assessments look at various factors to see if you can return to your job or any other job.

  • Skills Evaluation: Assess your job skills and whether they apply to another type of work.
  • Work History Review: Look at the jobs you’ve done in the past and what skills you used.
  • Physical and Mental Ability: Determine if your physical and mental capacities are enough to perform certain tasks.

These assessments help to paint a clearer picture of how your disability affects your work life. They can make the difference in your claim’s success.

Appealing a Denied Claim

Getting a denial on your long-term disability claim can feel like hitting a brick wall. But don’t worry; it’s not the end. There are steps you can take to appeal the decision and get the benefits you deserve. Let’s dive into the key steps of the appeal process to make sure you’re well-prepared.

Understanding Denial Reasons

Before appealing, it’s crucial to understand why your insurance company denied your claim. Insurers usually provide a denial letter outlining the reasons. Common reasons include:

  • Insufficient Medical Evidence: Your medical records may not fully support your disability claim.
  • Missed Deadlines: Filing after the deadline can lead to automatic denial.
  • Policy Exclusions: Your policy might exclude some conditions.

To address these issues:

  1. Review the Denial Letter: Read the letter to understand the specific reasons.
  2. Consult Your Doctor: Discuss the denial with your healthcare provider to see if additional medical documentation is needed.
  3. Meet Deadlines: Ensure that you submit all future paperwork on time.

Gathering Additional Evidence

Compiling evidence to support your appeal is essential. Building a strong case with comprehensive evidence can significantly improve your chances of winning the appeal.

This can include:

  • New Medical Reports: Updated records and reports from your doctor that clearly state your condition and limitations.
  • Diagnostic Tests: Additional tests like MRIs or X-rays that provide concrete proof of your disability.
  • Witness Statements: Letters from family, friends, or co-workers who can attest to how your condition affects your daily life.

Navigating the appeal process can be complex and stressful. Getting legal help can make a big difference. Here’s why:

  1. Expert Knowledge: Lawyers specializing in disability claims know the ins and outs of the process.
  2. Guidance on Evidence: They can help identify what additional evidence you need to support your claim and how to present it effectively.
  3. Handle Communications: They manage all communication with the insurance company, reducing your stress.

Appealing a denied claim might seem daunting, but with a clear understanding of why it was denied, the right evidence, and possibly some legal help, you’ll be in a much stronger position to get the benefits you need.

Ortiz Law Firm Can Help You Appeal a Long-Term Disability Denial

Facing a long-term disability denial can be incredibly stressful. You thought you had everything in order, only to receive a denial letter. But this is where Ortiz Law Firm comes into play. Our expertise could be the deciding factor in turning your situation around. Let’s explore how we can help you through this tough process.

Specialized Expertise in Disability Claims

We specialize in long-term disability appeals and lawsuits. This isn’t just what we do – it’s what we excel at. Understanding the complexities of these claims is our bread and butter. When you’re dealing with something as important as your financial future, you want specialists on your side.

Free Initial Consultation

Working with our firm is easy because we offer a free initial consultation. This allows you to understand what we can do for you without any financial risk. It’s a chance to discuss your case, see what went wrong, and determine an appeal strategy.

  • Case Evaluation: We look over your denial letter and understand the reasons behind it.
  • Strategic Planning: Together, we’ll figure out the best course of action to strengthen your appeal.

If you need help with your long-term disability claim, don’t hesitate to reach out. Call us at (888) 321-8131 for a consultation to discuss your case.

For more information about the long-term disability process, download a free copy of my book, The Top Ten Mistakes That Will Destroy a Long-Term Disability Claim.