Strategies Long-Term Disability Insurance Companies Use to Deny Claims

A significant number of spouses and parents who are sole providers for their families obtain long term disability insurance to provide peace of mind.  The primary function of this form of coverage is to replace some amount of your lost income if you become unable to work for a prolonged period of time.  Most individuals who have paid premiums and otherwise complied with the terms of their policy, expect their coverage to take affect when the unexpected occurs.  However, insurance companies have strong financial incentives to make these claims go away without paying benefits specified in the policy.  As Florida long term disability insurers face declining profits and rising payouts, the law has become stricter in terms of requiring carriers to pay valid claims.  This blog post provides an overview of strategies used by Florida insurance companies to take advantage of policyholders.

Asserting a Generic Claim Denial: Insurance carriers routinely engage in a classic case of “hide the ball” crouched in the vague or ambiguous language of a claim denial.  Insurance carriers will often provide a fairly “pro forma” denial letter which will attempt to shift blame to the insured by citing a failure to provide sufficient evidence establishing disability under the terms of the policy.  Despite this basis for denying the claim, the insurer will not provide specifics about the needed information or identify the documentation that is missing.  The tone of the denial might well create the impression that you only need provide a little more information and suggest that you forward diagnostic imaging tests, blood tests, medical reports, etc.  This approach is designed to lull the claimant into appealing the denial without the benefit of legal counsel.  A final denial typically forecloses the option to present supplemental evidence even if an insured later files a lawsuit.  Therefore, the insurer would prefer that the policyholder decide what to submit rather than an experienced long-term disability attorney who has successfully appealed many such denials.

Providing an Inaccurate Vocational Report: Insurers often deny coverage based on the assertion that the policyholder has the ability to engage in work in some capacity even one that is far removed from the insured’s job prior to suffering injury.  The insurer could provide a vocational report that lists the kinds of jobs the insured allegedly could perform.  The report might highlight your educational background, work experience, and aptitude to prove that you could work in a job you have never even heard of prior to your claim.  Our law firm often obtains an independent vocational expert who will dispute the claim that you can engage in the suggested jobs based on the nature of your medical restrictions or a lack of the appropriate training and job skills.

Disregarding the Impact of Pain Medication: Long-term disability insurers frequently assume that an insured can return to work with the assistance of drugs to manage pain.  However, this basis for denial does not take into account the side effects of pain medications.  Powerful narcotics prescribed to alleviate pain might interfere with your ability to safely operate a motor vehicle.  If you live in an area with poor public transportation, the side effects of pain drugs might prevent you from commuting to work.  Even if you can still drive a vehicle or alternate transportation is arranged, you might be unable to engage in work because the pain medication interferes with the concentration or mental clarity needed to effectively perform your job duties.

Disputing the Restrictions Outlined by Your Physician: When your doctor examines and treats you, your physician will develop an understanding of your functional limitations.  Your physician might indicate that you cannot sit or stand for more than an hour at a time without a break or that you cannot lift more than twenty pounds.  Insurance companies often dispute these restrictions by having a doctor paid by the insurance company produce a report that disputes these limitations even though he or she has never even examined you.  This basis for denial frequently involves “cherry-picking” details in your medical records while ignoring other information and the context surrounding the carefully selected facts.  A strategy for getting around this insurance company tactic is to obtain a functional capacity evaluation.  The insured’s treating physician can refer the insured for this objective test, which is typically performed by a physical therapist.  The policyholder’s ability to bend, kneel, reach, crawl, lift, and perform other physical tasks will be evaluated.  When your physician defines your work restrictions based on this scientifically verified evaluation process, the court might well find this the most accurate means of determining your ability to work.

Our Miami long-term disability insurance claims law firm invites you to contact us if your insurance carrier refusing to comply with its contractual obligation.  If you are an insured with questions about long term disability insurance claims, you are invited to contact our law firm to speak to an experienced Miami insurance claims attorney.  My law firm specializes in representing policyholders in claims disputes in Miami and throughout Florida. Click here to read about some of our case results.  The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations. No Recovery, No Lawyer Fees. Call 305-461-1095 or Toll Free 1-866-71-CLAIM. 

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