You aren’t eligible. There are many “eligibility” criteria which must be met in order to meet the provisions of your Plan–you must be in an Eligible Class; you must be working a certain number of hours (20 or 30, generally); your condition may not be pre-existing; your impairment must not be self-inflicted; etc. Generally, if you do not meet the eligibility requirements, your claim will not be paid at all, and it will be denied within a very short period of time. Numerous claims are denied each day by insurers because the claimants do not meet eligibility provisions in their policies. And, rightfully so. Any employee who does not meet the eligibility requirements in group policy is not entitled to benefits. If, after examining your employer’s LTD group policy, you have questions about your eligibility for benefits, contact your HR benefits representative right away. It is extremely important to read the policy and understand all eligibility requirements BEFORE going out on disability. Most disability insurers will investigate eligibility for benefits as a first priority. Any individual who fails to meet eligibility requirements is not entitled to benefits and generally the claim is denied.
You do not meet the definition of disability. Almost all disability claim denials fall into this category. All group LTD Plans contain a provision describing under what conditions an employee may qualify for benefits. Generally, these include: “are unable to perform the material and substantial duties of your own or any occupation, and you must have at least a 20% earnings loss.” Whether or not the employee can perform the substantial duties of his/her own or any occupation is largely a matter of documented opinion made by the insurance company using the credentials and expertise of Certified Vocational/Rehabilitation Specialists.
There is no objective evidence to support your claim for total disability. Most group LTD polices do not contain any provision requiring “objective medical evidence” as a burden of proof of disability. Still, almost all disability insurers give “no objective evidence” as a cause for termination of benefits. The “objective evidence standard” is simply an internal strategy allowing the claims specialist to deny claims submitted for impairments for which medical science has yet to find a mode of “objective evidence.” Impairments such as mental disorders, fibromyalgia, chronic fatigue, lupus, SLE, Lyme disease, CRPS and many others are often denied for no other reason than the absence of “objective medical evidence.” Also, you should ensure your doctor’s documentation describes any objective evidence that does exist, and ask him/her to address the issue of objective evidence in any response made to your insurer. Your primary care providers should always address whether your symptoms are consistent with your diagnosis.
We have spoken to your doctor and he/she agrees with us. If you suspect your doctor is not telling you about conversations with the insurance company, request a copy of your patient file, which is your right to obtain under HIPAA. Any paper exchanged between your doctor and the insurance company should be in your file. You should always try to maintain an open, honest relationship with your doctor, and discuss all aspects of your medical condition as well as your claim with him/her. Ask your doctor to keep you informed should the disability insurer contact his office for records or a doc-to-doc call.
Your impairment is self-reported. This is “lack of objective medical evidence” in sheep’s clothing. Albeit, some new policy series of LTD now contain provisions which allow the disability insurer to deny or limit the benefits for self-reported impairments by naming them specifically. Some policies even list specific impairments such as headaches, chronic pain, blurry vision, ringing in ears, fatigue etc. It isn’t surprising. Self-reported impairments are those symptoms for which there are no medical tests known to “objectify” the diagnosis. The only “proof”, if you will, is that you tell your doctor the symptoms, and as a result, your physician makes a “clinical” diagnosis. Check your policy and locate any provisions which address self-reported impairments.
Our in-house “Board Certified” Physician has concluded… Don’t be intimidated by these credentials, but it is important your physicians hold equivalent or better credentials than those of the in-house insurance physicians. For example, most disability insurers will not regard medical documentation from: 1) chiropractors 2) occupational therapists 3) homeopathic physicians 4) acupuncturists or 5) physician assistants or unlicensed physical therapists as credible. Read your policy carefully, paying particular attention to the definition of “Physician” and mentions of regular and appropriate care.
You have been paid 24 months under the mental and nervous or self-reported provisions of your policy.Not all, but most group LTD policies, and some IDI policies, limit benefits for mental and nervous disorders and self-reported impairments to 12 or 24 months. The problem with this is often classifying co-morbid complaints, inaccurately, into primary and secondary diagnoses. For example, fibromyalgia has two elements, one physical, and one mental, requiring counseling. Disability insurers like to classify fibromyalgia as a mental disorder first, and then as a “secondary” physical impairment. Doing so, limits benefits to 24 months, when in fact fibromyalgia is a physical syndrome not exclusively a mental one.
You are not disabled from performing ANY OCCUPATION. Not all, but most group LTD polices are either 2, 3, or 5 year own occupation policies. This means that for the first 2, 3, 5 years, you must prove you cannot perform your own occupation. After that, the definition of disability more closely resembles that of social security in that you must show you are unable to perform ANY occupation for which you have training, education or experience. The ANY OCCUPATION INVESTIGATION is too detailed to describe in this writing, but if your claim is denied after 24, 36, or 60 months, you should consult a professional attorney to assist you with your appeal.
You are not receiving “appropriate care”. I think it’s fair to say that any individual who is claiming total disability should consult a qualified physician on a regular basis. All group LTD policies require the attendance, care and treatment of a qualified physician with a specialty for the impairment claimed. In addition, “regular and appropriate” care is required at a frequency deemed appropriate by the medical community. For example, if a claimant is diagnosed with a serious mental disorder requiring ECT treatments, but is seeing a family physician every two months, the disability insurer may conclude there is no regular treatment. In other words, the claimant must be receiving care sufficient to cause him/her to improve over time. If the disability insurer concludes the individual is not receiving “appropriate or regular care”, normally the claim can be denied.
Surveillance- Inconsistent reports of physical activity.Technically, group LTD claims cannot be denied on the basis of surveillance alone. There is no policy provision allowing surveillance as the cause for a claim denial. The purpose of surveillance is to document and prove inconsistent reports of physical activity. For example, if a claimant informs the claims specialist they are unable to walk, but are seen jogging several miles, there is reason to challenge the credibility of the insured. Since the disability insurer cannot deny your claim based on surveillance alone, the company will usually send the surveillance CD to your physician and ask him/her comment. Once your physician sides with the insurance company, you are no longer considered disabled, and the disability insurer can then deny the claim, claiming you no longer meet the definition of disability given in the provisions of your policy. There are times when surveillance places the insured in a Catch-22 position. Many impairments actually require exercise and the continuance of regular activity in order to get better. Often, your treating physician includes a certain amount of exercise and activity in the treatment plan. The key is to be consistent in your reporting to the disability insurer.
Each claim circumstance is unique, but it is important to start off the new year knowing the major reasons why claims are denied so that moving forward insureds and claimants can side-step denials by routinely supporting claims to counter all of the above. It is said that attorneys never ask questions they already do not know the answer to. The above is your “in the know” when managing claims.
If you know what your insurer is likely to do, you know what to do about it!