Long-Term Disability Denials: 12 Reasons Your Claim Could Be Denied

When applying for long-term disability (LTD) insurance benefits, you must know that disability insurance companies deny many claims. Even if your disability insurance claim is initially approved, you need to know that your insurance company can terminate or cut off your benefits.

If the insurance company decides you are no longer disabled, they can terminate your benefits with very little notice. Sometimes, claimants are unaware until they do not receive payment.

There are multiple reasons long-term disability coverage can be denied or canceled. Whether you have coverage under a group plan governed by the Employee Retirement Income Security Act (ERISA) or an individual disability insurance policy, reviewing your policy for reasons the carrier could terminate your claim is always essential. Here, we will discuss the most common reasons long-term disability claims are denied.

RELATED POST: Top Reasons Why LTD Insurance Companies Deny Claims

Long-Term Disability Denials Explained

There is Insufficient Evidence to Support Your Claim

Long-term disability insurance companies often deny claims because they say there is insufficient evidence or objective medical findings to support the claim. For example, in a case involving back pain, if there is an x-ray, then perhaps better evidence would be an MRI or a CT scan. In a mental health claim, if cognitive deficits or difficulty thinking and processing information are an issue, neuropsychological testing may be a good piece of evidence.

You Do Not Meet the Definition of Disability

You must always look at the actual definition of disability in your policy. Each policy specifically defines how they evaluate the term disability. For example, under most policies, you’re disabled if you cannot perform all or substantially all of the material duties of your occupation, but you must look at the definition under your policy.

Another part of the definition is that it often changes over time, such that after two years, it’s not just whether you can do your job but whether you can do other occupations. Be aware of how the insurance policy defines disability in your policy.

Clerical or Procedural Errors in Your Claim

The claim may contain clerical or procedural errors. For example, the claimant, their doctor, or their employer may not have completed the necessary form to process the case or completed it incorrectly. Another procedural error is if you didn’t bring the claim in time. In most cases, you have a specific time frame to bring your long-term disability case to the insurance company’s attention.

You Failed to Provide Required Documents

Missing deadlines or failing to submit necessary medical records and documentation requested by the insurance company can result in the denial or suspension of your disability benefits.

The Insurance Company Reassessed Your Claim

Periodic reassessments of your medical condition are common in long-term disability claims. If there is evidence of medical improvement in your condition that suggests you are no longer fully disabled, or the insurance company determines you no longer meet the criteria for disability, they may cease your payments.

You Did Not Apply for Social Security Benefits

Did you know that under most long-term disability insurance policies, the insurance company can require you to apply for Social Security Disability (SSD) benefits? The reason is to help offset the payment of disability benefits by the insurance company. Under most policies, if you receive Social Security Disability Insurance, the insurance company will only have to pay you the difference between your Social Security Disability benefit amount and your long-term disability benefit amount.

Most policies include a provision requiring you to pursue an SSDI claim, which will save the insurance company lots of money. Failure to comply could result in the termination of disability insurance claims, so you should continue through the appeal process if your insurance company denies your claim.

Harmful Video and Social Media Surveillance Evidence

Your disability insurance carrier may conduct surveillance if the claims adjustor handling your long-term disability claim thinks you are not being entirely truthful about your symptoms and limitations. During this time, the insurance company can hire a private investigator to monitor your activities and take pictures or videos of anything they see that contradicts what you have told the insurance company. 

Insurance companies will likely conduct video surveillance when they know you will be out and about. Insurers regularly schedule surveillance concurrently with an independent medical examination (IME). Since the insurance companies know you will have to leave your home to attend the examination, they can be confident that the investigator will successfully obtain surveillance video.

The LTD insurance company can also monitor your social media accounts on Facebook, Instagram, and TikTok platforms. Insurers often deny disability claims because the claimant’s posts and photos contradict the symptoms and limitations you reported to the insurance company.

For example, you post a picture of yourself riding a rollercoaster at the fair but claim to have a severe neck injury. Most people with severe neck pain would not be riding a rollercoaster. A disability insurance company may use this evidence to deny your long-term disability claim.

An Unfavorable Peer Review or Independent Medical Examination

We frequently review cases where the insurance company has denied a long-term disability claim following an independent physician consultant report or an independent medical examination. The insurance company can have your disability claim reviewed by an “independent physician consultant” (IPC) or “peer review” physician, or you could be scheduled to attend an independent medical evaluation (IME), which is an exam conducted by medical professionals that are not associated with your case currently.

In both situations, the “independent” physician probably hasn’t reviewed all of your medical records (if any) and will likely issue a report questioning any opinions published by your treating physicians and asserting that the medical evidence does not meet the definition of disability.

My Doctor Says I Can’t Work, So Why Was My Claim Denied?

Your insurance company may deny your claim even if your doctor says you can’t work. Suppose insurance says your long-term disability claim has been denied and cites your IME or IPC report as the determining factor. In that case, you need to consult a long-term disability attorney. A long-term disability denial is not the end of your disability case.

An LTD attorney can hire medical experts to conduct another IME on your behalf and hire vocational experts to support the fact that you cannot work. There could be missing medical records, which our law firm can help to obtain. We will also work to get additional medical records and statements from your doctors disputing the IME or IPC report.

Policy Exclusions and Limitations

There may be policy exclusions for specific illnesses or injuries. For example, let’s say that the injury that leads to the disability that is the basis for the claim is a result of a self-inflicted wound. Some long-term disability policies will not cover a self-inflicted injury. Or, let’s say that the injury was incurred during criminal activity. Many policies will say you cannot receive coverage for an injury you received while engaged in criminal activity, which could be another basis for the denial. There may also be a cap on how long claimants can claim benefits for certain illnesses or injuries.

Pre-Existing Conditions

Insurance companies often deny claims based on a pre-existing medical condition. A pre-existing medical exclusion usually applies if the employee has recently started working for the employer. In most instances, if your disability begins within one year of employment and you receive treatment for that same condition three months before your job starts, your pre-existing condition may be excluded from coverage.

Your insurance company’s definition of a “pre-existing condition” will be stated explicitly in your policy. A sample clause from an Aetna long-term disability policy is as follows:

“No benefit is payable for any disability that is caused by or substantially contributed to by a pre-existing condition or medical or surgical treatment of a pre-existing condition and starts before the end of the first 12 months following your effective date of coverage. A disease or injury is pre-existing if, during the three months right before your effective date of coverage, it was diagnosed. Or you received medical treatment, care, or services for the disease or injury. Or you took drugs or medicines prescribed or recommended by a physician for the disease or injury.”

Let’s say your effective date of coverage is January 1, 2021, and that you went out of work in April of 2021 due to a heart attack. The insurance company gets all the medical records, and they go back to October, November, and December 2020 to see if you were getting any treatment for a heart problem and found that you were taking blood pressure medication for high blood pressure.

The insurance company will argue that this treatment was related to a heart condition or that you took drugs or medicines prescribed or recommended by a physician to treat that type of condition. The insurer may deny your claim because you were experiencing blood pressure problems during the lookback period.

In that type of case, our disability lawyer would argue that there’s a distinction between high blood pressure and ultimately stopping work due to a heart attack. A new and materially different condition caused you to stop working. You’ll need to identify either A) a condition that you did not get treatment for during the lookback period or B) that your condition is so materially different than what you received treatment for during the lookback period that it does not meet the criteria for pre-existing conditions, and that you should still be entitled to LTD insurance benefits.

Mental Health Conditions

Most long-term disability policies have a maximum payout of 24 months for a disability claim for mental health conditions. These conditions could include medical conditions like depression (including postpartum), bipolar disorder, PTSD, and anxiety. The insurance company claims these illnesses are difficult to prove with medical testing and lab reports. They can be faked or exaggerated. Although these illnesses are severe, you must verify the existence of your illness and the resulting limitations. That is very hard to do.

Self-Reported Symptoms Limitation

Many insurance companies are limiting long-term disability insurance coverage for non-verifiable medical conditions such as migraine headaches and fibromyalgia under the self-reported symptoms limitation clause of the LTD policy. This clause is sometimes called the non-verifiable condition limitation.

Self-reported symptoms mean the symptoms you report to your doctor are not verifiable using tests, procedures, or clinical examinations typically accepted in medicine. Examples of self-reported symptoms include, but are not limited to, headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness, and loss of energy.

Here is a sample clause taken from a Unum plan:

Disabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness, alcoholism or drug abuse have a limited pay period up to 24 months.

If your medical records do not contain objective medical evidence to support your subjective symptoms and limitations, the insurance company may deny your LTD claim. For example, here is a federal court case summary in which Aetna rejected a claim. Aetna won the argument that an insurance company can require objective medical evidence of functional limitations.

Other Chronic Medical Conditions

Some LTD policies have a maximum payout for chronic illnesses like arthritis, back pain, and carpal tunnel syndrome. Other may have limitations for specific categories of impairments, such as:

• Musculoskeletal disorders.
• Neuromuscular disorders.
• Soft tissue disorders.
• Chronic fatigue conditions.
• Chemical and environmental sensitivities.

Conditions associated with lifestyle choices like alcoholism, COPD from tobacco use, or other diseases related to drugs or alcohol use could also result in a termination of benefits after two years. Check your policy for limitations that could affect your claim.

You Are Not Following Your Treatment Plan

The claims adjuster will ask you to submit proof that you are continuing treatment, which helps to prove that your condition is severe enough to receive long-term disability benefits. Your treatment plan for your condition may be supplemental to your general healthcare. Claims are often denied because the claimant is not receiving appropriate care or following their doctor’s prescribed treatment plan.

• If the doctor prescribes a specific treatment that may improve the claimant’s medical condition to the point where they may even be able to return to work, but the claimant’s not undergoing that treatment, that can be a basis for denial due to non-compliance.
• Suppose you are seeing a primary doctor for overall health, but your treatment plan for your heart condition is with a cardiologist. In that case, you want to ensure you always see your cardiologist.
• Try not to miss any of your scheduled appointments, and if you do, be prepared to explain why. If you miss appointments or scheduled procedures, the insurance company will assume your condition is no longer as severe and may terminate benefits.

You Do Not Meet the Non-Medical Requirements

To have coverage, the claimant must meet all the eligibility requirements under the policy, and some of those requirements may be non-medical. For example, most policies require employees to work a certain number of hours or days before they become eligible for long-term disability coverage. I’ve seen denials where the insurance company claims the claimant didn’t work enough days or hours for coverage under the policy.

Even if your claim is initially approved and you remain disabled, most long-term disability insurance policies will only pay benefits until you reach retirement age, usually between 62 and 67. However, there are some exceptions to this—for example, if you apply for benefits over the age of 60, your benefits may have a “minimum benefit period” that may extend into the claimant’s initial retirement years. Check your policy for the exact wording on age-out dates and restrictions that apply to your long-term disability claim.

You Returned to Work

Many long-term disability claims are terminated because the claimant returns to work while receiving LTD benefits. Remember, the reason behind receiving benefits is you are saying you can’t work. Going back to work would most certainly disprove that. However, if you have an “own occupation” policy, you may be able to perform another occupation while receiving benefits.

Discuss Your Long-Term Disability Denial with a National Disability Insurance Attorney

There are many reasons why long-term disability claims are denied or why an insurance company may terminate them. Using these situations as a guide can help you continue to receive benefits for a longer period. However, if your disability claim has been denied, you should speak with a long-term disability attorney as soon as possible so you can file your appeal before the deadline. In many cases, you only have 180 days to file an appeal.

Although based in Florida, Nick Ortiz and the experienced legal team at the Ortiz Law Firm represent claimants across the United States. We have successfully appealed long-term disability denials from major disability insurance companies like New York Life Group Benefit Solutions (formerly Cigna), Lincoln Financial, Reliance Standard, Prudential, and Hartford. If you’d like to speak to an experienced long-term disability lawyer, contact us at (888) 321-8131 to schedule a free case evaluation.

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