Common Reasons for Long-Term Disability Insurance Denials

An injury that prohibits you from returning to work does not only impact your mental state, but also your finances.  When you are not able to earn the income you are accustomed to making, it is often difficult to keep up on the bills and household expenses.  For people who have long-term disability insurance, they may feel a sense of relief knowing that they will be able to qualify for income benefits.  However, many individuals find themselves in a situation where they are denied disability income benefits.  While there can be many reasons for a disability insurance denial, if the insurance company is acting in bad faith, the decision may be challenged.

Long-term disability benefits are designed to assist a person who is disabled pursuant to the policy definition.  If the worker applies for benefits and is approved, then the insurance company may be paying benefits for an extended period of time.  Some of the most common reasons for denials of long-term disability insurance benefits are outlined below.

There was a pre-existing condition.
Some disability insurance policies will exclude a pre-existing condition for up to 12 months.  A pre-existing condition is generally defined as a medical ailment that was treated within a specified number of months before coverage began.  Pre-existing conditions are common reasons for long-term disability insurance claim denials.

Lack of objective medical findings.
Insurers want to see, what they deem, clear medical evidence that supports your disability.  The objective findings may include x-rays or blood tests. Basically, an insurer is looking for what they see as concrete proof that there is a disability.  Some long-term disability policies specifically state that in order to qualify for benefits, objective findings must be available.  However, not all policies outline this requirement.

You can still perform your job.
A claims reviewer will thoroughly scrutinize your ability to perform your job duties.  The reviewer will research the definition of your job and the related tasks as defined by the national economy.  A claim can be denied on the basis of a generalized description of your job requirements, even if your job is more strenuous than the average.  If you have been denied disability income benefits based on the reviewer’s findings, be sure to request an explanation.  A careful review of your policy's definition of disability is necessary.

Symptoms are self-reported.
Self-reported symptoms, which can include headaches or fatigue, are often limited or excluded from disability insurance policies.  These symptoms are hard to document through objective findings and insurers may deny a claim on this basis.  If an insurer denies a claim, even though the policy does not specifically mention the limited liability or exclusion of self-reported symptoms, you may be able to challenge the decision.

Not pursuing physician care and proper medical treatment.
Many insurers require that you are under regular care of a physician.  However, policies are not always clear on the definition of “regular care,” which leaves room for interpretation.  Some claims may also be denied because the insurance company did not feel that you were receiving proper medical treatment.  This reason for denial can also be argued.

Long-term disability insurance is a complicated matter.  An experienced disability insurance attorney can assist you if you have been denied benefits.  Contact J.P. Gonzalez-Sirgo, P.A. at 866-71-CLAIM if you have received a denial of your disability insurance claim.