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Understanding Why Administrators Deny Claims

If you have a long-term disability (LTD) policy through your employer, the federally enacted Employee Retirement Income Security Act (ERISA) governs your LTD policy. Pursuant to ERISA, your disability application is reviewed and decided by claim administrators, usually employed by the insurance company. Given that insurance carriers frequently have a financial conflict of interest, it is not surprising that denied ERISA claims include even legitimate claims.

There are many reasons insurers deny claims. Understanding denied ERISA claims and why they happen could help you present the best application package possible at both the administrative and, if necessary, federal court. At Uscher, Quiat, Uscher & Russo, P.C., we can help.

Insufficient Medical Evidence

One of the most common reasons for denied ERISA claims is because of insufficient medical evidence.

  • Regular medical treatment. It is almost impossible to obtain benefits for a long-term disability claim if you are not receiving regular medical treatment. You are expected to visit your treating physicians on regular intervals, without a break in treatment or frequent cancellations and missed appointments. Most policies require that you be under the regular care of a physician for the condition which disables you.
  • Incomplete medical records. Sometimes, denied ERISA claims occur because the claims administrator failed to obtain your complete medical records. Claims administrators have no incentive to ensure they have your complete records. The best way to ensure the administrator has all of your medical records is by providing them yourself.
  • Doctor’s statement. A crucial factor in proving your disability is your treating physician’s opinion, usually expressed in an attending physician statement (APS). The opinion should include your treatment history, diagnosis, supporting evidence of your diagnosis, prognosis, and, importantly, your restrictions and limitations on your work abilities (and daily life).

Not Meeting Your Policy’s “Disability” Definition

Another common reason for denied ERISA claims is because you do not meet the policy’s “disability” definition, which you can find in your policy. There are generally two definitions:

  • “Own occupation” – you have a disability that precludes you from performing the duties of your particular occupation.
  • “Any occupation” – more narrowly defined, you have a disability that precludes you from performing the duties of any occupation.

There are LTD policies that transition from “own occupation” to “any occupation” after a period of time, usually 24 months. Your policy also provides excluded conditions or conditions with limited benefits. Typically, coverage excludes preexisting conditions as defined by the policy. Conditions diagnosed based on your subjective complaints, rather than objective evidence, may be limited to 24 months. These conditions include depression, anxiety, chronic headaches and chronic fatigue syndrome.

Images Inconsistent With Your Claim

Whether you are applying for benefits or already receiving benefits, your insurer may ask investigators to take video surveillance of you without your knowledge. If you are performing activities inconsistent with your claim — e.g., carrying a gallon of milk  (about 8 lbs) even though your physician states you cannot carry more than 5 lbs — the insurer can use the images to support a denial. This is true even if it does not prove you’re disabled.

For example, people diagnosed with fibromyalgia report having “good and bad days.” If they have you on video on your “good day,” it is enough proof to support a denial or termination of your benefits.

ERISA claims are denied also because of images found on your social media. This may include pictures of you skiing even though you claim your chronic back pain restricts your ability to work.

Missed Deadlines

Note the deadlines for filing and appealing your claim. For instance, ERISA gives you 180 days to appeal your initial denial. Failure to do so could waive your right to appeal even to federal court.

Contact A New Jersey And New York/New York ERISA Attorney If You Have a Denied ERISA Claim

For more information about why ERISA claims are denied, or if your claim has been denied, contact our seasoned ERISA attorney with Uscher, Quiat, Uscher & Russo, P.C., at 201-781-5645 or send us an email.