The Employee Retirement Income Act of 1974 (ERISA) allows for long-term disability claims to be assessed by a claim administrator working for the insurance company. The problem with this law is that it was drafted in 1974, hence it does not reflect the current changes occurring in the labor market.
A general analysis of the law will tell you that to a large extent it favors the interests of the insurance companies. This makes it easier for the claim administrator to get away with denying innocent employees their rightful share of benefits.
The thing you have to understand is that conflict of interests may make the claim administrators deny even the deserving employees their rights. The reason for this is very simple. Being an employee of the insurance company, they have an obligation to protect the company’s asset and bottom line.
Approving many long-term disability claims may seem to contradict this motive as it may bring about huge financial losses to the organization. This being the case, it is in your best interest to understand some of the reasons the claim may be rejected. Consider them as important tips for when filling the application form. The reasons include:
Failure to Meet the Disability Qualifications
Every insurance company has developed its own policies on the long term disability qualifications as informed by ERISA. Under these policies, the insurance may either choose to define long-term disability under the terms of “any occupation” or “own occupation”. Under the “any occupation” definition, you are considered disabled if your medical condition prevents you from performing tasks associated with any line of work. “Own occupation” disability, on the other hand, is when you cannot perform tasks associated with your respective job.
Therefore based on these definitions, the insurance can use the following grounds to deny your claims:
- Your policy is under the “any occupation” category yet your disability only limits your ability to perform your specific job-related tasks
- You had earlier been awarded benefits under the “own occupation” policy but it transformed into “any occupation” policy after a period of two years.
- Your insurance used some vague or general wording when defining the term “occupation” in your policy.
Failure to Produce Sufficient Medical Evidence
When filling your claim form, there is a section where your education is expected to fill. There is also another section requiring to provide evidence that may help support claims. These are two important sections that you cannot afford to play with when filling your form. This is the only chance the insurance company offers you to prove the severity of your medical condition. Some of the grounds insurances have used in the past to deny claims include:
- Failure to adhere to medical appointments/ treatments
- Failure to provide laboratory test or imaging scans conducted to help treat your condition
- Contradictory doctor’s report
- Failure to attach all the relevant medical records
Having a Pre-existing or Excluded Condition
The thing you have to understand about insurance companies is that they try as much to avoid taking up more liability than they should. Therefore, their policies will usually include clauses that help them achieve this objective. On the issue of pre-existing medical conditions, the long-term disability policy will not cover any disability associated with these conditions for a period extending to one year.
The same waiting period applies if you decide to improve your coverage plan. A claim may also be denied if the disability was caused by conditions excluded by the policy such as substance abuse.
Failure to Meet Submission Deadlines
It is always important to remember that there are set deadlines for the submission of long-term disability benefits claims. The same applies when placing an appeal for a verdict made in relation to your filed claims. These deadlines are usually guided by the stipulations set under ERISA law. Therefore, it is upon you to adhere to these guidelines to avoid giving the claim administrator a reason to reject your claim.
Irregular Medical Treatment
One thing you can be sure about insurance companies is that they do not let go of their money that easily. A simple mistake such as missing a doctor’s appointment for the said medical condition may automatically disqualify your claim. Therefore, when claiming long-term disability benefits, it is important you attend all the set doctor’s appointment. This also works to your advantage because you will also have more medical records to present as evidence.
Inconsistencies of Video Surveillance with Your Claim
If you thought that you have had it rough with the insurance companies, wait till they start using video surveillance against you. When filing for a long-term disability claim, the company may decide to hire a private investigator to trail you and record your activities. Their aim is simply searching for inconsistencies in your report.
For example, you may claim that the medical condition makes it hard for you to lift heavy objects. If they are lucky enough to catch you on surveillance lifting heavy objects, then this may be enough evidence to disqualify your claim. The same case applies to the video on how you got injured in the first place. Inconsistencies between the workplace surveillance videos and your report may be enough grounds for disqualification.
From this analysis, it is evident that there are several legitimate reasons that the claim administrator can use to deny your long-term disability claim. In other cases, the administrator may also use illegitimate reasons with a view of protecting the interests of the insurance company.