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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Guardian Long-Term Disability Denial Lawyer

Last Updated: October 3, 2024 | Reviewed and Edited by: Ortiz Law Firm

The Guardian Life Insurance Company of America provides disability insurance plans through its affiliate, Berkshire Life Insurance Company of America. However, it is Guardian that evaluates claims for benefits, pays benefits owed, and issues denial letters. Although Guardian Life is better than most insurers at approving claims, they still wrongfully deny many long-term disability claims.

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At the Ortiz Law Firm, many of the long-term disability claims we’ve handled have involved Guardian Life, making us highly familiar with their approach to denying or delaying claims. Whether it’s challenging a denial or litigating a case in court, we know the common tactics they use to try to avoid paying benefits. Our extensive experience with Guardian gives us a unique ability to anticipate their moves and respond with the most effective strategies.

Nick Ortiz, a disability attorney with nationwide experience appealing and litigating Guardian disability denials, has also built strong connections with many of the defense attorneys that Guardian Life frequently relies on. Nick is in regular contact with these attorneys—often speaking to them multiple times per week—and has developed a rapport that allows for more efficient communication and case resolution. His direct access, including the ability to call them on their personal cell phones, often speeds up negotiations and provides a significant advantage for our clients.

If Guardian has wrongfully denied or terminated your claim, Nick Ortiz offers a free case review to discuss your legal rights and options—call (888) 321-8131 or click the button below to get started.

Get a Free Case Review

Why Was My Guardian Disability Insurance Claim Denied?

There are many, many reasons why Guardian denies disability claims. The most common reasons for a Guardian’s long-term disability denial are:

  • Guardian determined that you do not meet the definition of disability as defined in your specific policy.
  • Guardian hired a physician to review your medical records, which stated that you are not eligible for disability benefits.
  • Guardian hired a private investigator to conduct surveillance and follow you with a camera or video recorder. Guardian then used the video footage as evidence that you can return to work.
  • Guardian sent you for an independent medical exam to evaluate your restrictions and limitations.
  • Your doctor stated that your medical condition does not prevent you from returning to work in some capacity or
  • Guardian hired a vocational expert to find jobs other than your own that you could perform daily.

If the Guardian has denied your claim, you must take action. The time available to file an appeal is usually 180 days from the date of the denial. Once the appeals are exhausted, claimants only have a limited time to sue their disability insurance companies.

RELATED POST: Guardian Denies LTD Benefits Because Claimant Was Not In Active Full-Time Service

Social Security Approved My Claim, So Why Was My LTD Claim Denied?

The requirements to qualify for Social Security Disability are very different from those for long-term disability benefits. Guardian may consider the SSA’s decision as evidence in your LTD case, but it does not guarantee approval.

Guardian will also consider whether much time has passed since the SSA approved your claim. Guardian may argue that the SSA considered evidence no longer current or relevant to your long-term disability claim.

Own Occupation/Any Occupation Policies

Guardian often issues disability insurance policies to licensed professionals and executives such as doctors, lawyers, accountants, and corporate employees. Since these are highly specialized occupations, most Guardian long-term disability insurance policies use an “Own Occupation” disability definition. Here is an example from an “own occupation” policy:

“A member is considered disabled if he or she has physical, mental, or emotional limits caused by a current sickness or injury and, due to these limits, he or she is:

  1. Not able to perform, on a full-time basis, the major duties of his or her own occupation and
  2. Not able to earn more than this plan’s maximum allowed income earned during a period of disability.

This own occupation definition remains in effect for your full benefit period.

For physicians, own occupation means the medical specialty or subspecialty practiced by the doctor right before the start of disability, provided:

  1. He or she is certified in such specialty or subspecialty by the American Board of Medical Specialties (ABMS);
  2. He or she carries malpractice insurance covering the full range of duties performed in this specialty or sub-specialty and
  3. For the 24 months immediately prior to disability, at least 60% of his or her insured earnings was professional service fee income attributable to the practice of this specialty or sub-specialty.”

However, it is common for long-term disability plans to use a definition of disability that changes after a certain period. This change in definition means that you must prove you cannot perform any occupation. The definition commonly changes from your occupation to any after you have received benefits for 24-48 months. Here is an example of an “any occupation” definition of disability:

“Disability or Disabled: These terms mean that a current sickness or injury causes physical or mental impairment to such a degree that the covered person is:

(1) During the elimination period and the own occupation period, not able to perform, on a full-time basis, the major duties of his or her own occupation.

(2) After the end of the own occupation period, not able to perform, on a full-time basis, the major duties of any gainful work.

The covered person is not disabled if he or she earns, or is able to earn, more than this plan’s maximum allowed disability earnings.

The covered person may be required, on average, to work more than 40 hours per week. In this case, he or she is not disabled if he or she is able to work for 40 hours per week.

Neither: (a) loss of a professional or occupational license; or (b) receipt of or entitlement to Social Security disability benefits; in and of themselves constitute disability under this plan.”

How to Appeal Denied Guardian Disability Claims

If you have a group disability plan through your employer, ERISA governs your claim. The ERISA (Employee Retirement Income Security Act) is a set of pro-insurance company regulations. ERISA law requires claimants to undergo the administrative appeal process before filing a lawsuit.

Under ERISA, you cannot submit additional evidence after you exhaust your appeals. Steps you can take to strengthen weak areas of your claim include:

  • Gather additional medical evidence. Your medical records alone may not be enough to bridge the gap between diagnosis and impairment. Ask your doctor to complete a residual functional capacity form or write a statement supporting your claim. It should explain how the specific symptoms of your condition disabled you.
  • Work with a vocational expert. A vocational expert assesses a claimant’s ability to perform a given occupation. Vocational experts are beneficial if you need to prove you cannot perform any occupation.
  • Obtain statements from family, friends, and coworkers. You can get a statement from anyone who has witnessed how your condition impairs your abilities. Most claimants have at least one person who has seen their disability. Additional statements regarding your limitations can strengthen your claim.

If you have an individual disability insurance plan, your disability insurance claim is exempt from ERISA regulations. You may not have to file an appeal and do not face the same restrictions regarding introducing new evidence. Another advantage of a non-ERISA policy is that claimants may bring a bad faith claim against Guardian. ERISA policies, on the other hand, do not allow bad faith claims.

How Ortiz Law Firm Can Help with Your Claim

If Guardian has denied or terminated your claim, contact Ortiz Law Firm to handle your appeal. We will obtain additional evidence to strengthen your claim during the appeal process. If Guardian denies your appeal, we can assist you in filing suit to recover your disability income insurance benefits.

We know that claimants who cannot work and are fighting for benefits cannot afford to hire a Guardian disability attorney. We represent our clients on a contingent fee basis, with no “out-of-pocket” costs. Our contingency fee agreement means you only pay an attorney’s fee if we successfully recover benefits. We will also advance expenses in your claim, including charges for medical records and court filing fees.

Get a Free Case Review

Request a Free Case Evaluation with a Guardian Long-Term Disability Denial Lawyer

It is easy for untrained claimants to misread or misunderstand a disability policy. We will review your policy and the details of your case. As part of our evaluation, we will explain what everything means for you in your claim. Call us today at (888) 321-8131 to get help obtaining the benefits you deserve.

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