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When you’ve paid an insurance company for a long-term disability policy and a time arrives when you need to use the policy you’ve paid for, it is extremely frustrating when the insurer denies your claim. Unfortunately, it’s not at all uncommon. Insurance companies make money by paying out as little as possible, so they rarely miss a chance to say “no.” And they’ve become quite adept at presenting legal arguments to suggest that you have no hope of succeeding if you file an appeal.

But the fact is that it often takes legal action to get the benefits you are entitled to under the terms of your policy. You will not only need to file an appeal, but you will need to present the right evidence at the right point in the process in order to win your case.

As a legal team that focuses on helping professionals gain full benefits under their disability insurance policies, we’ve seen countless situations where policyholders were denied benefits because they missed a critical step in the process of filing a claim or appealing a denial. While every situation has its own unique complications, here are some general steps to keep in mind when you’re appealing a denial of long-term disability benefits from an insurance company.

Know the Type of Policy You Have

Disability insurance is a blanket term that covers a lot of different types of programs. If you search the term online, most of the information you’ll find relates to Social Security Disability Insurance, a program administered by the federal government and paid for by your payroll taxes. The rules and processes that apply to that program are nothing like those that apply to disability insurance policies provided by insurance companies.

Disability insurance policies offered through insurance companies are either purchased collectively as a group or individually by a single policyholder. Employers often purchase group policies to offer as a benefit to employees. Many professionals, such as physicians, accountants, attorneys, and executives, purchase individual private disability insurance to protect themselves, their families, and their businesses in case an illness, injury, or condition prevents them from practicing their profession.

Group insurance policies offered by employers are governed by different laws than private policies purchased by individual policyholders, and the processes of filing appeals differ. So the first step when you need to file an appeal is to determine which type of policy you have. An attorney who provides assistance with disability insurance issues can help with the assessment, and also advise and advocate for you during the appeals process.

Understand Why Your Claim Was Denied

To successfully appeal a denial of benefits, you need to understand why your claim was denied so that you can correct deficiencies in the claim. It is important to note that while your insurance company is supposed to provide a reason for the denial, they may, in fact, have several reasons and give you only one of them. That means you could address the issue they raised and still face a denial on appeal. 

To gain approval for benefits, you need to satisfy all of the policy requirements, and those requirements are often not very clearly stated. The insurance industry frequently relies on terms of art that have a specialized and detailed meaning within the industry but are not always comprehensible to those who are not intimately familiar with the claims process.

It is also important to be aware that approval for short-term disability benefits does not necessarily translate to approval for long-term disability benefits, even if they are provided by the same insurance company. The terms and requirements often differ between policies, and the departments that evaluate claims will not always communicate or share information. Any assumption that the insurance company received the information they needed for your long-term disability claim when you applied for short-term disability benefits will probably turn out to be unfounded, so it is best to approach each process from scratch.

Medical Documentation

One of the most common reasons that claims for long-term disability insurance benefits get denied is that the claimant failed to provide sufficient documentation to support the claim. Remember that what ordinary people consider sufficient and what insurance companies demand may be two entirely different things.

Among other things, you will need a thorough set of medical records documenting the extent of your disabling condition. The records should show that you are under ongoing care from a doctor—insurance policies are often written in such a way that companies can deny or terminate benefits if you have not received appropriate care for your condition or you are not following up as recommended. It is essential to continue receiving treatment for your condition even when that poses a challenge.

In addition to basic records of your visits, tests, and treatments, you will also need a special statement from your attending physician that explains your condition in detail and how that condition impacts your ability to perform the functions needed to work. Insurance companies are notorious for providing short forms for these statements, giving you the impression that they only need a sentence or two about your condition. In reality, you need to ensure that the statement from your physician is accurate and detailed. When you work with an experienced disability insurance attorney during the claims or appeal process, your legal advisor can ensure that you submit a statement with the requisite degree of detail.

Definition of Disability

Another common reason disability insurers deny claims is that they assert that the condition described in the claim does not meet the policy’s definition of a covered disability. It is important to understand the definition provided under your specific policy because there can be tremendous variations. For instance, you need to know whether your policy requires you to show that you are unable to perform your “own occupation” or whether it is necessary to demonstrate that you are unable to perform “any occupation” that you could conceivably be expected to undertake. 

It is obviously much more challenging to establish under the second definition than the first. You may need evidence from vocational experts to satisfy this requirement. During your appeal, you will need to ensure that you present adequate evidence to show how your condition meets the policy’s standard for disability.

Exclusions

A third common reason that disability claims are denied is that insurance companies insist that your condition fits under one of the exclusions listed in your policy. Insurance companies often interpret exclusions very broadly to deny claims that should be covered, particularly in situations involving mental disabilities.

The Appeals Process

The specific process involved in pursuing an appeal will vary depending on the terms of your policy. In most cases, the policy will specify a process for filing an internal appeal within the company. For group insurance policies covered by ERISA, internal appeals must usually be completed before you can seek remedies in federal court. Individual insurance policies may also include provisions requiring you to go through one or more internal appeals, but if a company is operating in bad faith or otherwise violating state law, your attorney may be able to move forward with a lawsuit without waiting months for the internal appeals process to conclude. Regardless of how the process begins, it is a good idea to gather and present persuasive evidence of your qualifications sooner rather than later because as the appeals process continues, your ability to submit new evidence may be limited.

The Right Guidance Can Make All the Difference When Appealing a Disability Insurance Denial

The process of appealing a denial of long-term disability benefits will be different in each case because it depends on the terms of the policy, the evidence available regarding the disability at issue, the laws that apply in the particular case, and many other factors. If you fail to comply with requirements in the policy or the applicable law, it may not be possible to obtain benefits even through an appeal. Assistance and guidance from a knowledgeable disability insurance attorney can make all the difference in the outcome of your appeal.

At Seltzer & Associates, we know the process can be confusing and frustrating. However, our decades of experience allow us to advocate successfully on behalf of professionals when filing an initial claim, appealing a denial, or contesting a termination of benefits. If you’ve been denied benefits under your long-term disability policy or want to be prepared to reduce the likelihood that your claim will be denied, schedule a free consultation with us to learn more about the assistance we can provide. Just call 888-699-4222 or contact us online to get started.