Long-Term Disability Insurance Claim Denial | California Insurance Law
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WAS YOUR CLAIM FOR LONG-TERM DISABILITY BENEFITS DENIED?

YOU’RE NOT ALONE. CALIFORNIA INSURANCE LAWYERS GIANELLI & MORRIS CAN HELP YOU GET THESE ESSENTIAL BENEFITS.

Insurance companies gladly accept costly premiums for years but turn down claims for technical errors or cut off benefits while you’re still disabled

Three million people apply for long-term disability benefits every year, and insurance companies turn down over half of them. Why do they do it, and how do they get away with it? They do it because consumers of long-term disability insurance tend to have high salaries, and paying out benefits over months or years is costly to the insurer’s bottom line. They get away with it because policyholders don’t understand how to deal with denials; either they don’t know they can appeal and fight these decisions, or they get so exhausted and frustrated dealing with endless requests for paperwork and documentation – all while suffering from a serious physical disability – that they simply give up.
Smart policyholders call an attorney to help them with a long-term disability claim denial, and the smartest call Gianelli & Morris. Our California insurance bad faith law firm has decades of experience working exclusively in the area of insurance law. We’ve fought for countless individuals who’ve been denied the benefits due under their policies. Call us if you’re having trouble getting the benefits you need and deserve under your long-term disability insurance policy. We’ll fight to see you get the benefits you’re entitled to.

What is Long-Term Disability Insurance?

Long-term disability insurance, or LTDI, is a form of insurance intended to provide you with replacement income in the event you become disabled from working because of an accident, illness or other disabling condition or event. The precise terms of your policy will dictate important features of your policy, such as what type of disability qualifies for benefits, how long you must be disabled to start receiving benefits, and how long these benefits last.

Long-term disability insurance can be purchased in a variety of ways: privately as an individual; through a group plan as an employer fringe benefit; or as a member of a professional association. Each option has its own pros and cons. For instance, a federal law known as ERISA covers most group plans and imposes strict timetables on when an employee can apply for benefits or file a lawsuit when a claim is unfairly denied. There are also strict rules on appealing claim denials and getting critical evidence before a judge. ERISA further requires an administrative process that is a crucial step even if you eventually have to go to court. On the plus side, all or part of a group plan is typically paid by the employer with pre-tax dollars.

A policy you purchase on your own is likely to have better benefits and terms, and you can use it to add to an employer’s group plan or as a standalone policy. However, private plans are typically scrutinized harder by insurance companies than group plans, and carriers find it easier to deny individual claims or to continually delay payment at a time when you don’t have a moment to waste. Since ERISA isn’t involved, there are fewer rules involved in fighting a denial, and you can take your claim to state court instead of federal court. Private plans are easier to afford when you are younger and not earning your top salary; it gets much harder and costlier to obtain later in your career or to convert a group policy to a private one if you leave your job.

If you are a member of a professional association that offers long-term disability insurance as a member benefit, you may find it easier to obtain coverage without any rigorous physical or medical history required. However, the policy offered by the association may not be the best one for you in terms of benefits and cost. You’ll be stuck with whatever plan the association offers, and there is no guarantee they’ll continue their relationship with the carrier, or that you’ll continue your relationship with the association.

Be aware when shopping for LTDI. Different policies have different definitions of what counts as a qualifying disability, as well as different limitations on payouts. Tax treatment may also be a factor to consider. Group plan premiums may be pre-tax, and individual payouts are generally tax-free.

Short-Term or Long-Term Disability Insurance?

Another consideration is whether to buy a short-term disability insurance (STDI) policy in addition to LTDI. A drawback of LTDI is that you may need to be disabled for 90 days or as long as six months or a year to be eligible for benefits, depending on your policy. LTDI policies count days you are disabled to meet their required “elimination period” or “accumulation period.” STDI benefits typically last three or six months and can carry you through an LTDI elimination period or accumulation period. If you don’t have the savings to live for 90 days until LTDI kicks in, STDI can be a lifesaver. STDI is especially attractive if offered through your employer or if you’re young enough so that it’s cheap enough to be affordable and valuable. If you do have STDI, you must be very careful how you go about filing a claim, because how the claim is handled can impact a later LTDI claim. It’s smart to talk to an experienced disability insurance lawyer before filing your STDI claim.

How do Insurance Companies Deny Long-Term Disability Claims?

One of the main ways insurance carriers find to deny LTDI claims is by alleging you failed to provide proof of loss in a timely manner. It may not be clear to you when you purchase the insurance what these requirements are, or you may have forgotten in the intervening years. While obtaining LTDI benefits is a priority after a disabling injury, it may not be the first thing on your mind. You’re busy dealing with doctors, hospitals and managing your recovery and may not immediately be thinking that there are deadlines involved in filing a claim. However, missing deadlines and other technical errors are common sources of LTDI claim denials.

Allegations that you provided improper or insufficient documentation is another tool in the insurer’s arsenal of weapons to deny your claim. Insurance companies require extensive documentation from you to support your claim that you are disabled from working over a long-term period. Generally, it’s up to your treating physician to document your diagnosis, prognosis and treatment and to certify work restrictions or other limitations that prevent you from working in your chosen field or other occupations.

These facts must be thoroughly supported in the medical record. Beyond a diagnosis, insurers require a detailed assessment of your functional limitations and their relationship to your occupation. The insurance company will look hard at these records and deny your claim for insufficient documentation if the record doesn’t meet their high, exacting standards.

Long-Term Disability Benefits Can Get Cut Off Short

Even if your claim for LTDI benefits is approved, you may find your benefits cut off far before you have fully recovered and while you still believe you are entitled to benefits. The insurance company is likely to be constantly reviewing your situation, requiring documentation month after month, and even conducting surveillance or unannounced visits, all in an attempt to find a way to say you are no longer disabled. Every request for documentation is another opportunity for the insurance company to say a record is incomplete or that the entire medical record is inconsistent. Sometimes the carrier simply decides you are ready to return to work based on statistical calculations that don’t take your particular condition into account at all.

Our California Long-Term Disability Insurance Attorneys Can Help You Get Your Benefits

Some doctors are experienced serving patients with LTDI claims and know what type of documentation to provide, but not all doctors know what is required or bother to take the time to provide the right kind of documentation. They are busy enough providing care and managing a practice without doing “extra” work to help you with your LTDI claim. Unfortunately, only providing a diagnosis and treatment notes is unlikely to pass muster. Our California insurance lawyers know what’s required, and we can help by working with your doctors and their staff to ensure your doctor’s office is generating the appropriate documentation needed to support your claim.

People sometimes damage their ability to fight a denial or termination of benefits by calling up the insurance company to complain. Talking to insurance companies is a bit like a suspect talking to police: anything you say can and will be used against you. Only the insurance company doesn’t have to give you that warning before you talk to them. We’re experienced LTDI claim denial lawyers. We know the right things to say and the right way to say them. Call us first, and let us be your voice and staunch advocate in dealing with insurance company denials or early termination of benefits.

Appealing a denial on your own can also be very dangerous. Whether appealing internally to the insurance company or to an administrative agency under ERISA rules, the documentation you provide in your appeal can impact what evidence makes it into court should you need to proceed with a lawsuit to get your benefits. As experienced attorneys and courtroom litigators, we handle your case right from the start, knowing what it takes to ultimately be successful in a challenge to an LTDI denial.

Call Gianelli & Morris for Long-Term Disability Insurance Claims Denials in California

For help with a denial of your LTDI claim or other long-term disability insurance issues, call the California insurance lawyers Gianelli & Morris at 213-489-1600 for a no-cost, confidential consultation. We’ll take the time to evaluate your situation and let you know how we can help.

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