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United Health Group is a disability and health insurance company. United Healthcare (UHC) is a specialty company that offers long-term disability insurance. Disability insurance, or disability income, replaces a portion of your income if you are unable to work due to a qualifying disability. Golden Rule Insurance Company, a United Healthcare company, is the underwriter and administrator of these disability insurance plans.
Unfortunately, United Healthcare does not always live up to its end of the bargain. Many claimants are shocked and dismayed by the hurdles United Healthcare puts in front of them when they file a claim. Despite your best efforts, you may still receive a denial.
For example, United Healthcare requests more and more paperwork as part of the “proof of loss” process. Sometimes UHC will have a doctor call and ask to speak to your healthcare provider. Your doctor may fill out a form incorrectly or become annoyed by United Healthcare’s numerous requests for information. All too often, deserving claimants must hire a United Healthcare disability lawyer to recover their rightful long-term disability benefits.
Why Was My United Healthcare Disability Claim Denied?
Insurance companies make money by collecting more in premiums than they pay out in benefits. The less they pay out in claims, the more profit they keep for shareholders. Once you understand this basic premise, you will understand why insurance companies deny even the best prepared disability claims. Here are some of the most common reasons United Healthcare denies claims:
Peer Review Evaluation
During a Peer Review Evaluation, United Healthcare will have one of their doctors review your claim. Their doctor may say that you have no significant limitations. The insurer will use this finding against you to deny your claim.
Vocational Analysis
During a vocational analysis, United Healthcare will have your claim reviewed by a vocational expert. This vocational expert may determine that you can still do your job (or other work for which you may be qualified).
A Change in the Definition of Disability
Insurers often deny claims after a change in the definition of disability. In most group plans, the definition of disability changes after two years. Here is an example of a disability definition that changes after 24 months of payments:
“The Covered Person is Disabled or has a Disability when We determine that:
- He is not Actively at Work and is unable to perform some or all of the Material and Substantial Duties of his Regular Occupation due to his Sickness or Injury.
- He has a 20% or more loss in Indexed Pre-Disability Monthly Earnings due solely to the same Sickness or Injury; and
- He is under the Regular Care of a Physician.
After 24 months of payments, the Covered Person is Disabled when We determine that due to the same Sickness or Injury, he is unable to perform some or all of the material and substantial duties of any Gainful Occupation for which he is reasonably fitted by education, training or experience and he continues to suffer a 40% or more loss in his Indexed Pre-Disability Monthly Earnings due solely to the Sickness or Injury.”
Insufficient Medical Evidence to Support a Claim
Your insurer may claim that there is insufficient medical evidence to support your claim. United Healthcare has gained a reputation for denying claims by claiming because of missing information or documentation. Insufficient medical evidence could also mean that UHC does not believe your condition is serious enough to qualify for benefits.
RELATED POST: Long-Term Disability Insurance Appeal Guide
Video and Social Media Surveillance
Insurers conduct surveillance in one of two ways: video surveillance and social media surveillance. United Healthcare may claim that your activities are inconsistent with your disability and terminate your benefits.
Mental Health Limitations
Disabilities due to mental illness usually have a limited pay period of 24 months. Insurers often deny claims at this point, even if the claimant also has a physical illness. Here is an example of a mental health limitation from a UHC policy:
“Disabilities due to Mental Illness or Substance Abuse have a limited pay period of 24 months. This is a lifetime cumulative maximum benefit period for Disabilities due to Mental Illness or Substance Abuse.
We will continue to send the Covered Person payments beyond the limited pay period if he is confined to a Hospital or Medical Facility. If he is still Disabled when he is discharged, We will send him payments for a recovery period of up to 90 days. If he becomes re-confined at any time during the recovery period and remains confined for at least 14 days in a row, We will send payments during that additional confinement and for one additional recovery period up to 90 more days.
In no case will benefits be paid beyond the Maximum Benefit Period.
Mental Illness means: any Sickness, disease or disorder, which is:
- Listed in the current edition of the Diagnostic and Statistical Manual of Mental Health Disorders (or any successor diagnostic manual) published by the American Psychiatric Association; and
- Usually treated by a mental health provider or other qualified provider, using psychotherapy, psychotropic drugs or other similar methods of Treatment.
Mental Illness includes any such conditions whether or not related to an underlying physical, genetic, chemical, organic or biological cause, although it may be associated with physical symptoms, manifestations or expressions.
For purposes of the Policy, Mental Illness does not include coma (unless a consequence of Substance Abuse), mental retardation or Alzheimer’s disease and other forms of dementia with an objectifiable organic basis.”
Click here to view UHC’s complete, redacted long-term disability insurance policy.
Appealing a United Healthcare Disability Denial
If you receive a denial letter in response to your application for benefits, do not despair and give up. You can appeal United Healthcare’s decision through their administrative appeal process.
It is important to take the appeal process seriously. This is your chance to stack the record with evidence to support your claim. Evidence to submit with your appeal may include:
- Additional medical records or vocational evaluations.
- Affidavits from witnesses such as family, friends, and co-workers.
It is also important to have an experienced long-term disability attorney assist you in the appeal process. An attorney can explain the reason for the denial and what you can do to fight back and win your claim. They will help you identify and obtain the evidence you need to strengthen your claim.
At the Ortiz Law Firm, we understand how complicated the appeals process can be. We also understand how important these benefits are to you and your family. You have enough to deal with in treating your medical condition, so let us take on the insurance company.
We have a “No Recovery, Zero Fee Guarantee.” This means our clients only pay a fee when disability benefits are recovered.
We cannot guarantee that your appeal will be successful. However, we will work diligently to prepare an appeal that is clear, concise, and complete with all necessary information.
What If United Healthcare Also Denies My Appeal?
Under ERISA, you may file a lawsuit in federal court after you have “exhausted” your appeals. Some ERISA policies require multiple appeals. ERISA usually governs group insurance policies purchased through an employee health plan. The consumer is better protected in non-ERISA claims. ERISA does not apply to your claim if you have an individual policy or are a government or church employee. This is why it is important to hire an attorney to explain your legal options to you.
United Healthcare Disability Denied? The Ortiz Law Firm Can Help
Our team has the skills and knowledge to appeal your claim denial and recover the benefits you deserve. We help claimants across the United States with wrongfully denied insurance claims. We can help you:
- Understand the reasoning behind the denial of your long-term disability benefits.
- Obtain additional medical records and evidence to submit with your appeal.
- Obtain opinions from your treating physicians regarding your impairments.
- Complete the appeal paperwork.
- File the appeal within the required time limits.
- File an ERISA lawsuit in federal court or a breach of contract lawsuit in state court; and
- Prepare your case for trial.
Call (888) 321-8131 to schedule a free case evaluation to discuss your claim for long-term disability insurance benefits.