With long-term disability denials, you can be informed that you do not qualify for benefits from the beginning or that you no longer qualify for benefits after a certain period.
Some of the most common reasons for denying claims include:
- Injury or condition not considered restrictive enough
You may be informed that your medical condition or injury is not considered serious enough to prevent you from going to work or is excluded from coverage as per the terms of the insurance policy.
Before accepting your claim, the insurance company will assess the limitations and restrictions caused specifically by your injury. The loss adjuster will decide whether your injuries are serious enough to prevent you from doing your job and this will largely depend on medical reports and the opinion of medical professionals.
Some conditions (and their symptoms) such as psychological conditions, brain injuries or chronic medical conditions like fibromyalgia or chronic fatigue syndrome, have few visible symptoms.
Standard types of imaging diagnostics or blood tests do not identify such conditions and so evidence of symptoms must be documented in medical reports. Otherwise, the insurance company can deny your claim based on a lack of medical evidence.
- Material misrepresentation or non-disclosure
Insurance companies frequently attempt to void policies for material misrepresentation (providing incorrect information) or non-disclosure (not telling them key information), thereby invalidating a policy.
A good example might be a pre-existing health condition that should have been declared before the policy was set up.
If your policy has lapsed due to non-payment of premiums, you may be ineligible for long-term disability coverage.
- A review of your case after surveillance
Some insurance companies hire private investigators to conduct photograph, video, and social media surveillance without the claimant’s knowledge. Within limits, this is legal and is done to try to catch claimants doing things that they say they can’t do (and therefore undermine their credibility and their claim).
As long as your claim is genuine and you have reported the truth, there is nothing to worry about. Surveillance will not help the insurance company.
However, if the evidence gathered contradicts your version of events, the insurer may deem you able to work and deny your claim or discontinue benefits.
- Breach of a rehabilitation clause
Most long-term disability policies have a rehabilitation clause.
This means that LTD benefits are paid as long as you get appropriate treatment for your condition from a qualified physician. Failure to do so may be deemed a breach of the clause and provide an excuse for the insurance company to terminate benefits.