What Is A Long Term Disability Claim & Why Do Insurance Companies Deny Them?

Long term disability claims are claims against an insurance company for failing to pay long term disability benefits. They protect individuals who suffer a disability from enduring large financial losses because they have lost their ability to perform their job duties. Common reasons for long term disability claims include cancer treatment, heart disease, pregnancy complications, back injuries and depression.

Long term disability insurers such as Reliance Standard, Liberty Mutual and Unum deny thousands of claims every year. While long term disability attorneys admit that some denials are certainly valid, they say that many more are not. So, why are so many long term disability claims denied?

Long term disability claim denied

Insurance companies deny long term disability claims for many reasons - or sometimes for no reason at all. Common long term disability claim denials include:

• Failing to meet the definition of disability. Every long term disability insurance policy defines the term "disability." In order to make a claim, your injury must fall within the meaning of that definition. If it does not, your long term disability claim will likely be denied.
• Failing to provide objective evidence. Insurance companies require objective evidence, or proof, which substantiates your disability and prevents you from working. Objective evidence can include test results from x-rays, MRIs (magnetic resonance imaging) or blood tests as well as a functional capacity evaluation which provides clinical evidence of whether you are physically able to perform the usual and customary duties of your occupation. Long term disability denials frequently occur when you cannot provide that information.

  For example, if you break your leg, an x-ray of the broken bone is objective evidence that you cannot perform your job as a mail carrier. However, not all injuries can be proven as clearly as a broken leg. Disabilities such as as fibromyalgia (a long-term, body-wide pain and tender points in joints, muscles, tendons and other soft tissues), depression and chronic back conditions cause many long term disability claims to be denied - simply because they can't be proven by clinical evidence. However, both types of claims may be payable.

• Having a pre-existing condition. A pre-existing condition is a medical condition for which the insured received some type of medical care three to six months prior to the insurance policy coverage effective date. Many long term disability policies have an exclusionary period of between 12 and 24 months in which long term disability claims are not allowed for a prior medical condition. However, that condition may be covered once the period expires.
• Engaging in an act listed as a policy exclusion. Nearly every long term disability insurance policy will contain a list of exclusions which result in long term disability denials. Common exclusions include disabilities caused intentionally by self-inflicted injuries, the result of a crime or illegal act or those arising from the use of alcohol or drugs.
• Failing to meet a contractual eligibility requirements. Many long term disability insurance policies obtained through employers generally contain eligibility requirements - and the failure to meet those can result in a long term disability denial. Common requirements include waiting periods in which a person must be employed for a certain amount of time or work a specified number of hours before being eligible for benefits.
• Misrepresenting yourself on the insurance application. Insurers require policyholders to complete an application in order to receive long term disability insurance - and a healthcare questionnaire asking for your medical history is part of that application. If the insurer later finds out that your answers were not completely truthful, it will likely deny your long term disability benefits and void the policy due to a material misrepresentation.

Long term disability denied

If you're dealing with a long term disability claim denial, contact a long term disability lawyer to discuss your situation. Insurance companies routinely deny claims for no reason whatsoever - knowing that many policyholders will simply give up. You don't have to.