Aug 15, 2025 - Disability Insurance, Disability Insurance Appeals, Long Term Disability Insurance by Seltzer & Associates
When a disabling condition interferes with your ability to practice your profession, surgery is often touted as the miracle cure. Surgeons will repair whatever isn’t functioning, your body will heal, and then you will be as good as new. At least, that usually seems to be the expectation.
The reality is often far different. Surgery may accomplish nothing helpful. Or it may not be enough to enable you to regain the functionality you need to perform delicate tasks. You may still be left with pain that prevents you from moving or even sitting comfortably, so that it remains impossible to focus for any considerable period of time.
Surgery doesn’t automatically fix everything. Physicians—particularly surgeons—recognize that sometimes, surgery doesn’t address the underlying problem at all. But disability insurance providers base their determinations on industry guidelines rather than individual experiences. They look at their chart, decide that you’ve had surgery and had enough time to recover, and that therefore you must be ready to work. And they’re not ready to listen to a word to the contrary.
In that type of situation, the experience and advocacy of a Philadelphia long-term disability appeal lawyer can prove extremely helpful. At Selzer & Associates, we focus our practice exclusively on disability insurance, so we understand how to succeed with a disability appeal when recovery from surgery or other treatment has not produced the results the insurance company expected. While we can’t provide tailored advice in an online article, here are some of the issues that often come into play when benefits are discontinued or a claim is denied because the insurance company thinks you should be ready to return to work.
The Disability Appeals Process May Differ Depending on Policy Requirements
If you’ve received notice that disability benefits have been denied or are about to be terminated, the notice may indicate that you are required to “exhaust all administrative remedies” before turning to litigation or other action to enforce your rights. Even if you didn’t get a notice with this language, the requirement may be buried in the fine print of your policy.
Insurance companies establish their own processes that policyholders must use as the first step in appealing an action or decision by the company. When you pay for your policy, you agree to abide by these procedures. However, you cannot agree to accept an insurance company’s actions that are in bad faith, and you still retain your legal rights. Whether or not the internal appeals process seems likely to produce a different result, you still need to comply with procedural requirements, including applicable deadlines.
An experienced attorney familiar with common requirements and fluent in deciphering the fine print of long-term disability insurance policies can help ensure that you preserve your rights by following all requirements to the letter. We understand the arguments and evidence that insurance companies find to be persuasive, so a team like ours can often help you succeed in obtaining a new decision and reinstated benefits. If our efforts at appeals and negotiation fail to produce the right outcome, the information we have gathered and prepared during the administrative appeals process can provide the basis for an appeal in court or through another process such as mediation.
The Right Records are Crucial
It is often quite difficult for a professional to prove that surgery or other treatment failed to produce the results needed to improve a disabling condition. There may be an almost limitless number of reasons why surgery was unsuccessful, even if it was performed properly. Sometimes, the damage had progressed too far. Other times, a co-morbid condition could be preventing recovery. Regardless of the reason, it is essential to gather the right evidence to demonstrate the outcome of the procedure and the continuing presence of the disabling condition.
Documenting symptoms such as numbness, tingling, or pain can be difficult. But physicians, dentists, physical therapists, and other professionals who rely on their trained sense of touch and who require dexterity to perform their jobs properly know that if these symptoms remain, it could be unethical for them to treat patients.
Keeping a detailed log of symptoms and their effects can provide a record of conditions that are difficult to document objectively, such as chronic pain. Specifically describing limitations each day can also be helpful. For instance, if the range of motion or ability to grip is limited, measuring and recording these limitations on a daily basis can provide a persuasive record that a disabling condition in the hand has not improved to the point that allows for a return to work. A Philadelphia long-term disability appeal lawyer can provide guidance on the types of records to seek and the information that should be journaled regularly.
Independent Medical Evaluations
When your disability insurance provider decides that, according to their recovery charts, your disabling condition should be healed, they might contact your primary physician to ask for a “return to work” date. Or they might require you to submit to an Independent Medical Evaluation (IME). These evaluations are very seldom independent. Instead, they are conducted by physicians who are well aware that they are working for the insurance company. They will often perform examinations that search only for positive indications and ignore evidence of continuing disability. The reports provided after an IME may not necessarily be false, but they often exclude critical information.
During an IME, it is important to be honest with the physician conducting the exam, but don’t expect an honest, unbiased report in return. It is a good idea to undergo another, truly independent examination so that you have your own evidence and report prepared to counter the “evidence” produced from the IME. Your disability insurance attorney can help you locate an independent physician who understands how to conduct this type of examination and how to write up a report that reflects your actual condition rather than the condition your insurance company wants or expects.
Understand the Risks of Returning to Work Too Early
When your insurance company is insisting that you need to return to work, it can be easy to convince yourself that you’re strong enough to manage. They may play on your sense of pride. After all, their goal is not your welfare but the maintenance of high profit margins. If they discontinue your benefits, they can keep more money.
Make sure you understand the legal ramifications before you make any attempt to return to work. Your policy may be worded in such a way that it allows your benefits to be reinstated if you try to work and find that you’re unable to continue. But the policy might also specify that any return to work prevents you from ever receiving further benefits based on that condition.
Returning to work before you are fully ready can cause a health impairment to grow worse. It could also potentially expose you to liability if you’re not functioning at full capacity mentally or physically. Talk to a knowledgeable insurance disability attorney about your options for appeals and the obligations of your policy before you make a decision about returning to work.
If You’re Not Ready to Return to Work, Selzer & Associates Can Appeal Your Insurance Company’s Decision on Your Disability
You know better than anyone what it takes to perform your job with the competence and stamina required in your profession. A disability insurance adjuster does not. Administrative employees at an insurance company should not be the ones determining whether you are ready to work.
If an insurance company insists that you have recovered and you know that you have not, we urge you to schedule a confidential, free consultation with a Philadelphia long-term disability appeal lawyer at Seltzer & Associates. Although we are based in Philadelphia, we have decades of experience helping professionals with disability insurance challenges all across the U.S. We understand the issues in ways few legal teams can match. Let’s discuss the next steps toward ensuring you have the benefits you deserve under your disability insurance policy.