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10 Common Reasons Long-Term Disability Insurance Claims Are Denied

Mon Feb 14th, 2022 on     Disability Insurance,    

It’s a scenario our Miami disability insurance lawyers have seen time and time again: You’ve been disabled and cannot work, and while you are worried about what the future holds, you are grateful for the long-term disability insurance policy you have in place. So you file your claim, only to have it denied by your insurer. 

There are various reasons why insurers deny claims, and knowing what they are can help you avoid this situation. But rest assured that even when your claim has been denied, it’s not the end of the road. One of the Miami disability insurance lawyers at Ver Ploeg Marino can help you recover the compensation you are owed under the terms of your long-term disability insurance policy.

Self-Reported Symptoms Exclusion

There are some medical conditions that are not able to be verified by a blood test, X-ray, or CAT scan. Instead, the symptoms are such that they are unable to be seen or corroborated by anyone other than the person experiencing them. Because of this, it is not uncommon for an insurer to deny coverage for these conditions. Examples include chronic fatigue, chronic pain, mental illness, and Fibromyalgia. 

Failure To Receive & Follow Through With Physician Treatment

When you file for long-term disability benefits, you will likely be required to receive medical treatment for your condition to receive your disability benefits. Many insurers dislike alternative treatment or therapy, relying on traditional medicine as evidence that you are receiving the mandated treatment. However, whether or not an insurer can direct your medical care, and to what extent, is a debatable topic. It is important to check the terms of your policy to see if it is required that your treatment be received from a “medical doctor.”

It is also important that you follow up with your doctor’s recommendations for continued treatment, as failure to do so may mean that your insurer will terminate your benefits.  

Failure to Communicate With Insurer

Your obligation to communicate with the insurer does not end after you file your claim, or even after your claim for long-term disability benefits has been approved. The insurance company will still need to communicate with you to obtain any updated information regarding your medical condition, and you need to provide this information to them. This documentation is used to verify that you continue to qualify for the benefits under the terms of your policy. The insurer may even request that you submit to another medical evaluation. This is typical, and should you fail to communicate with your insurer after their repeated efforts to contact you, your long-term disability benefits may be terminated. 

Medical Professional Disputes Disability Existence or Severity

If a medical professional does not agree that your disability exists, or that it exists but is not as severe as you believe it is, the insurer may use this as a reason to deny your claim. This is usually a determination made by a physician that the insurer requires you to visit. 

Pre-Existing Conditions

When you claim disability benefits for a condition, the insurance company will often try to determine whether or not your condition is considered to be pre-existing. If it is, they are able to deny coverage under the pre-existing condition exclusion clause of your policy. 

A pre-existing condition exclusion is typically applicable within the first year after the policy is issued, although this is not always the case. If you sought medical treatment for the condition in the time period before your insurance went into effect (period of exclusion), the insurer will likely deem the condition pre-existing and deny coverage. Insurers will also deny your claim if it was non-treated and it is reasonable that you should have sought treatment during a period of exclusion.

Late Filing & Missed Deadlines

Deadlines matter. Missing them can cause an insurance company to deny your claim, and may affect your ability to file an appeal. Check the terms of your policy to determine when your claim has to be filed and other important deadlines. If you have questions, one of the Miami disability insurance lawyers from Ver Ploeg & Marino can help you.

Issues With Credibility

Believe it or not, insurance companies will take drastic steps to prove that you are not suffering from a disability and do not qualify for benefits. This includes surveillance of your home, as well as having you followed. They are allowed to photograph or video you and provide it as evidence that you have not been forthcoming regarding your condition. They may also speak with friends and family, as well as record your activities. They are not, however, allowed in your home unless they are invited. 

The insurance company can also look at your social media accounts to find information that brings your credibility into question. 

Condition Not Covered

Many people mistakenly believe that long-term disability insurance plans will cover any condition that renders them unable to work. This is not true. It is important to check the terms of your specific policy to determine what it does and does not cover. Some common exclusions are disabilities that are the result of a crime and injuries that are self-inflicted. 

Failure to Meet Precise Definition of Disability

Your policy will list how your insurer defines “disability.” If the insurer does not believe your condition meets the exact definition, your claim may be denied.

Failure to Support Your Claim

The insurance company makes its decision to deny or approve your claim based on the evidence you provide to them. Therefore, that information needs to be thorough and all-inclusive. If you fail to provide the documentation required to substantiate your claim, it will be denied. Common documents that you need to submit for review may include:

  • Medical Records
  • Prescription Records
  • Testing Results
  • History of Employment & Income
  • Physician Notes

Speak With One Of The Miami Disability Insurance Lawyers at Ver Ploeg & Marino

If your claim for long-term disability benefits has been denied by your insurer, you don’t have to just accept their decision. Instead, you need to seek counsel from Miami disability insurance lawyers that have experience helping policyholders just like you recover the compensation they are owed. You may reach us via our contact page.

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