Filing a claim for long-term disability insurance (LTD) benefits is a stressful experience for most of the people who go through the process. Unfortunately, many initial long-term disability claims are denied. The result is that someone who already feels unwell enough to miss work must now figure out how to fight their denied long-term disability claims in order to begin the LTD claim denial appeal process. Many people who have to leave the workforce sooner than they would have wished to find themselves appealing denied long-term disability claims. Often, they seek assistance from experienced professionals as they navigate the process. A guide to appealing LTD denials may help you to understand the steps involved in appealing denied long-term disability claims and determine the kinds of support you may need.
Why Would a Long-Term Disability Claim Be Denied?
How to fight denied long-term disability claims depends partly on the reason or reasons given by the insurance company in their denial of the claim. The essential purpose of an appeal is to counter the points cited in the denial. Many people find this frustrating, as the experience can feel like being required to change insurance adjusters’ minds about a decision already made. However, the structure of the process also means that the reasons cited for denial provide claimants with a framework for identifying the kinds of evidence they will need to provide and the points they will need to prove in appealing a denied long-term disability claim.
The reasons that can be cited for denial are themselves set by the terms of the LTD policy. Some of the more common reasons for denied long-term disability claims include:
- The disability is caused by a pre-existing condition.
- The disability is linked to a condition excluded under the terms of the policy.
- There is insufficient medical evidence to support the claim.
- The individual’s condition does not meet the definition of disability under the terms of the policy.
Sometimes a denial may cite more than one reason. As a general guide to appealing LTD denials, though, additional medical evidence is likely to play a role in your appeal even if the insufficiency of medical evidence is not explicitly cited as a reason for the denial.
Why Is It So Hard To Get Long-Term Disability Approved?
All insurance companies make their profits in essentially the same way: by taking in more money in premiums than they pay out in benefits. Obviously insurance companies who routinely fail to provide adequate coverage will struggle to gain contracts, even from employer-sponsored group plans that are negotiated by human resources (HR) teams rather than selected personally by individuals. Insurance companies that fail to honor the terms of their policies can run afoul of state and federal regulations, depending on their circumstances. Within those constraints, every insurer has considerable financial incentive to limit the number of approved claims and the amount paid for each claim approved.
Denied Long-Term Disability Claims: Understanding Insurance as a Business
The types of strategies insurance companies use to deny claims depend partly on the type of insurance involved. For instance, missed filing deadlines may be used to deny homeowners’ insurance claims, and lower repair estimates from the insurance claims adjuster compared to those submitted by the homeowner are a common tactic for reducing the amounts paid for those claims. In health insurance, prior authorization requirements help to set choke points in the path of claim approvals, and many claims for surgical procedures are denied on the basis of the insurer’s claim that the procedure is not “medically necessary” in a particular case.
How To Fight Denied Long-Term Disability: Recognizing the Rationale for Refusing Benefits
Individuals appealing denied long-term disability claims are often based on internal determinations that the person filing the claim for LTD benefits is actually able to work and therefore not eligible. If there is no dispute over whether the individual can participate in the workforce, then sometimes the insurance company will issue a denial on the grounds that the person’s disability stems from a cause that is excluded under the terms of the specific policy.
Typical examples of these exclusions would be for pre-existing conditions, regardless of diagnosis. Another reason might be a diagnosis that appears on a list of conditions explicitly excluded from coverage under the policy. These exclusion lists vary from policy to policy, but mental health conditions are among their most common targets. You may consider reviewing your policy’s exclusion clauses with a disability attorney if an excluded condition is cited as the reason for denial in your case.
LTD Claim Denial Appeal Process: Key Steps
Always granted that the specifics will depend on the circumstances of each unique situation, there are a few steps most people can expect to go through in appealing denied long-term disability claims. An effective LTD claim denial appeal process is likely to involve all of the following:
- Review of denial letter and insurance policy
- Collection of additional evidence, as appropriate
- Drafting and submission of formal appeal letter
- Submission of additional evidence in support of appeal letter
In instances where the insurance company’s denial appears to be out of line with the facts represented in your initial LTD claim filing, it may be appropriate to request a copy of your file from the insurer so that you can review it for completeness and accuracy. In these cases, correcting the information already in the file may sometimes be as important as collecting and providing additional information in support of the denied long-term disability claim.
Review Both the Denial Letter and the Terms of Your Policy
When an insurance provider denies a claim for benefits, the company is generally required to provide the policyholder with a reason for the denial. Review the denial letter carefully, as its contents will give you the point or points your appeal must effectively counter. The way you frame your “counterargument,” or rebuttal, will need to be based not just on the language used in the letter denying your claim, but on the terms of the policy under which the claim was denied. In essence, for each reason the denial letter gives for why your claim for LTD benefits is subject to denial under the terms of your policy, you will need to respond by presenting evidence and explaining how that evidence shows that your situation instead meets the policy’s criteria for eligibility.
Review Your Evidence
If the insurance claim reviewer has cited a lack of medical evidence as a reason for denying your LTD claim, then you can know from the start that you will need to provide more medical documentation as part of the LTD claim denial appeal process. In other instances, you may not be able to determine what other evidence is appropriate until you have compared the denial letter to the documentation you submitted at the outside of the LTD claim filing process.
In either case, reviewing the medical evidence already submitted and the medical facts readily available to you can often be a useful step in deciding how to fight denied long-term disability claims. For many people, this review of evidence marks a crucial “turning point” in their LTD claim denial appeal process at which they find it helpful to turn to experts for advice. Consider looking for a disability attorney in your jurisdiction who can help you understand the legalities of the denial and the corresponding standards that will apply to appealing denied long-term disability claims.
Draft Your Letter of Appeal
If you have decided to work with a disability attorney in your LTD claim denial appeal process, he or she will likely draft the formal letter of appeal on your behalf. Otherwise, you may be able to gain some traction by thinking back to the essay-writing assignments you may have had in college or even high school: The denial letter lays out the points you will need to address to complete your “essay” assignment, and the terms of the policy establish the kinds of evidence that will be considered acceptable as support.
How To Fight Denied Long-Term Disability: Introducing Your Argument
The letter of appeal you send to the insurance company will be formatted like any other business letter. However, the way it presents information will be very similar to the way points are organized in the standard expository or “argumentative” essays many people were assigned as students. This is the type of essay that takes a position on some point in dispute, states that position as a thesis, and then supports the thesis by providing evidence and explaining how that evidence proves that the thesis is valid.
For the purposes of navigating the LTD claim denial appeal process, the point in dispute is whether you should receive LTD benefits. The insurance company has already identified their position by sending a denial letter. To set up the “thesis” that you are appealing because your claim should be considered eligible, craft an introduction that:
- Provides your name and policy number
- Gives the submission date for the original LTD claim as well as the date marked on your denial letter
- Acknowledges the reason for denial identified in the letter
- Clearly states that you are appealing the denial
The remainder of your letter will address and rebut the specific reason or reasons cited for denying your claim. This means that the insurance company’s own reasoning can function as a guide to appealing LTD denial in your case.
How To Fight Denied Long-Term Disability: Connecting Evidence to Eligibility
For each reason given by the insurer, state the corresponding reason why it does not apply, then identify a piece of documentation that provides evidence supporting your point. For instance, if you have been denied LTD benefits on the grounds of a pre-existing condition, you might name the date of the first medical visit related to your disability and reference the portion of your medical record documenting your appointment and the reason for your visit on that date.
Rather than relying on the insurance claims reviewer to draw the inference you want, explain in detail how the documents you are referencing show what you say they do. If the reason for denial is “pre-existing condition,” and one of the pieces of evidence submitted in your appeal is the record of the first medical visit related to your disability, name the relevant attachment in your letter and state explicitly that it is a record of your initial attempt to seek diagnosis and treatment. Spell out the gap between your coverage eligibility date and the date of that office visit. Depending on the circumstances, you may also want to consider having copies of your medical records from the “lookback” period specified in your LTD policy sent to show the absence of any related medical visits during that time period. Be sure to attach each piece of documentation you mention, or clearly reference the submitted attachment, depending on your insurer’s document handling system.
How To Fight Denied Long-Term Disability: Use Quotes To Support Your Points
Just as you likely used quotes to support your points when writing essays in college or high school, you may need to refer to your notes, or your healthcare provider’s notes, from the medical assessments related to your disability. In thinking about how to fight denied long-term disability claims, pay special attention to any mentions by your healthcare providers that suggest you cannot do something the denial suggests you can or should be able to do. Notes that rule out a possible diagnosis for an excluded condition that the insurance claim reviewer asserts might explain your condition may be especially helpful. Whatever forms of evidence you use, remember throughout that the goal is to explain, in explicit terms, how each individual piece disproves a specific reason the insurance company has given for denying your LTD claim.
Guide to Appealing LTD Denial: Tips for Appealing Denied Long-Term Disability Claims
The LTD claim denial appeal process can be extremely frustrating. For most people, the outcome of their appeal has high personal and financial stakes. The long waiting periods sometimes involved in appealing denied long-term disability claims can make an already stressful situation worse. In addition, nobody has an instinctive understanding of how to fight denied long-term disability applications. Each step of the process has to be discovered, internalized, and then put into practice. A guide to appealing LTD denials may serve as a useful point of reference, but many people also find it helpful to work with professionals for support. Consider looking for an advocacy group that provides resources for individuals with your disability. A conversation with an attorney in your area who practices in disability law may provide practical perspective on how the basic steps of the LTD claim denial appeal process apply to your situation.
