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Home > Practice Areas > Long-Term Disability Benefit Denials

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 LTD, 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 LTD. 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 LTD. A drawback of LTD 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. LTD 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 LTD elimination period or accumulation period. If you don’t have the savings to live for 90 days until LTD 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 LTD 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 LTD 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 LTD 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 LTD 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 LTD 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 LTD 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 LTD 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 LTD 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 LTD denial.

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

For help with a denial of your LTD 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.

Long Term Disability (LTD) for Doctors and Professionals

What to Do When Your Long-Term Disability Claim is Denied

Long-term disability (LTD) insurance is meant to provide income replacement for a specified period if you become unable to work due to injury or illness. These policies cover millions of business executives and licensed professionals across a number of fields. Doctors, in particular, can benefit from LTD coverage, and, indeed, millions of physicians, surgeons and medical doctors in the U.S. count on this coverage should they become disabled from working.

Sadly, policyholders who submit claims for LTD benefits are rejected by their insurers more than 50% of the time. Despite being learned professionals and experts in their field, physicians and surgeons are not experts in the field of insurance law and often don’t know how to deal with an insurance denial. At Gianelli & Morris, insurance law is all we do. If your claim for LTD benefits was denied, our insurance law experts will take on the job of getting you the full value of your claim sooner rather than later. Learn more about LTD denial issues below, and call Gianelli & Morris if you’re a California doctor whose LTD claim was turned down.

What LTD Does/Why You Need It

Long-term disability insurance provides replacement income if you become disabled and can’t perform the duties of your profession. The exact terms depend on your specific policy, but LTD policies, in general, provide up to 60% of income and cover illness, disease, mental nervous disorder, accident or injury. Payment of benefits might turn, in part, on whether the disability is considered total, partial or presumptive:

  • Total disability means you can’t work presently, but you might recover from the disability and be able to return to work.

  • Partial disability means you are able to work but not at your regular capacity. The insurer might pay a percentage of benefits in this instance, depending on the policy.

  • Presumptive disability means that the condition is presumed to be permanent, and you should receive benefits for the entire payment period. Loss of sight, hearing, speech or the loss of two limbs are common types of presumptive disability.

Own Occupation Versus Any Occupation LTD Insurance

One of the most important facts to know about your LTD policy is whether it is an “Own Occupation” or an “Any Occupation” policy. “Own Occupation” means you cannot perform the duties of your profession: if you are a surgeon, you cannot operate, for instance. In a true Own Occupation policy, you could work elsewhere or in some other capacity and still receive benefits. In contrast, if the policy is “Any Occupation,” then the insurer can refuse to pay benefits so long as you can work in any occupation that you are fit for.

The precise language in your policy is controlling. For instance, you may have an Own Occupation policy that only pays benefits if you cannot work in any occupation that you are reasonably suited for, given your education, training and experience. This might not be what you thought you were getting when the agent sold you an Own Occupation policy. Some Own Occupation policies will also pay a transitional benefit if you are working in another occupation, although the benefit will be offset by the money you earn. Other Own Occupation policies will only pay benefits if you are not engaged to work in any other occupation. In other words, you get benefits even if you can take another job, so long as you don’t actually do so. Still other policies are hybrids, switching from Own Occupation to Any Occupation after a period of time set forth in the policy.

Doctors, in particular, run into difficulties getting their LTD claims approved because of the nature of their profession. If you have an Own Occupation policy, the definition of disability should be specific to your specialty. Insurers often lack the understanding of your specialty and will misconstrue it. They’ll confuse your ability to practice in some fashion with your ability to perform in your specialty area.

An Any Occupation LTD policy is relatively inexpensive compared to an Own Occupation policy because you are less likely to be so totally disabled you can’t work at all. An Own Occupation policy is much more valuable to you as a surgeon or other skilled professional, but you’ll likely need help getting the benefit of your policy and convincing the insurer you qualify for benefits.

Why LTD Claims Get Denied (or Delayed and Delayed)

LTD claims are notorious not just for their high rate of denials, but also for the interminable delays policyholders must go through to get their benefits or keep them from being cut short. Here are some of the main ways insurance companies drag out the approval process and why they eventually deny claims.

  • The insurance company maintains they are still reviewing the medical records and need more time to decide.

  • The insurance company is checking to see if you had any pre-existing conditions that were undisclosed in the application process.

  • The insurance company looks for any incomplete or inaccurate information on your initial application or any monthly claimant statement.

  • The insurance company claims it is not getting the communication it needs from the physician who is treating you, e.g., doctors are not sending over medical records, not returning calls, or not properly submitting the attending physician statement.

  • The insurance company asks for documentation every month, and every month their request is for something new and different. Eventually, they’ll find some error, inconsistency, or failure to provide requested documentation they can use as a basis to deny your claim.

Why You Need a Lawyer for an LTD Claim

You may have already known you needed LTD insurance, and perhaps you’ve been covered for years. If you ever have to make a claim, you’ll find that having a lawyer on your side can prove invaluable to receiving benefits in an industry where more than half of all claims are rejected. An experienced long-term disability insurance attorney can help you in many ways. For instance:

  • Choosing the correct date of disability is a critical factor that must be appropriately considered as early as the initial claim application.

  • An expert LTD insurance lawyer knows how to establish your eligibility for benefits under an Own Occupation LTD policy.

  • Your lawyer can work with your treating physician to make sure they send the right documents to the insurer in the proper format and don’t unwittingly sabotage your claim.

  • All communication with the insurer goes through your lawyer. You don’t have to waste your time and energy dealing with the insurer, and you don’t have to worry that you’ll make some error that lets the insurer turn down your claim.

  • If your claim is denied, your attorney will know the appropriate next step to take, whether resubmitting the application with additional documentation, pursuing an internal appeal, or filing a lawsuit.

  • The insurance company will evaluate your claim every month, causing unreasonable delays or leading to early termination of your benefits. You need expert help in responding to requests and dealing with insurer communications.

  • They have lawyers evaluating your situation and developing legal bases to deny your claim or cut off your benefits. Level the playing field by having your own attorney and choosing one with as much experience or more than the insurance company lawyers.

Gianelli & Morris Takes on the Insurance Giants and Wins

Our California insurance law firm has gone up against the largest insurers in the state time and again and has consistently prevailed through individual claims and class actions across the spectrum of insurance law. Call our office if you are having difficulty getting approved for LTD benefits from your insurance provider. Some of the biggest providers of LTD policies are:

  • Lincoln Financial
  • Reliance Standard
  • Liberty Mutual
  • Mutual of Omaha
  • Northwest Mutual
  • Ameritas
  • Principal Financial Group
  • The Standard
  • Mass Mutual
  • Guardian
  • Ohio National Financial Services
  • Prudential
  • Met Life
  • The Hartford
  • UNUM

You Are a Medical Expert. Let Our Legal Experts Help You With Your LTD Claim.

LTD insurance policies can be lengthy, dense and highly technical. Despite your advanced education and training in the medical field, you might still find the esoteric language in your policy to be virtually impenetrable. At Gianelli & Morris, we live and breathe insurance policies and can quickly interpret your policy and let you know where you stand if your benefits have been denied. Whether your policy is Own Occupation or Any Occupation, ERISA or non-ERISA, we have the knowledge, skills and resources necessary to make sure you get the benefits of the policy you paid for. Call Gianelli & Morris today for a free consultation at 213-489-1600.

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