Denied Long-Term Disability Claims: How a Philadelphia Lawyer Can Help

Long-term disability insurance is supposed to be a safety net for injured workers. You pay your premiums on time every month and then you suffer an injury on the job. You turn to your disability insurance policy to help replace your lost income believing that they will pay. You file all of the paperwork to begin your benefits but, shockingly, you receive a denial letter from the insurance company.

Unfortunately, this scenario plays out for employees on a daily basis. The reasons for the initial denial can vary and be numerous. Fortunately, this is not usually the end of the road if you have a legitimate disability claim. Knowing how and why you were denied long-term benefits is essential because your situation may be salvageable.

If you have received a denial from your Philadelphia long-term disability carrier, you should contact a long-term disability lawyer who can evaluate your situation and provide the help that you need.

What is Long-Term Disability?

Long-term disability is essentially an insurance policy that is designed to kick in when a certain event occurs. Long-term insurance, unlike Social Security Disability, is a private policy provided by an insurance company rather than the government. Like homeowners insurance, car insurance, and medical insurance, you count on this coverage to provide financial assistance during times of need. A long-term disability policy is typically provided as a benefit of your employment. Although your employer may offer the policy, the employer is not the insurer. Instead, they contract with a third-party insurance company to provide the benefit to employees.

When an employee suffers a qualifying injury at work, they are normally eligible to begin receiving long-term disability payments. These payments are designed to replace wages for employees who have suffered serious and disabling injuries. When an employee receives benefits, they are typically paid out a set amount on a monthly basis for an indefinite period of time so long as they remain disabled.

Why are Long-Term Disability Claims Denied?

Although the process sometimes goes smoothly, long-term disability claims are routinely denied upon initial review. The process of applying for disability benefits can initially feel user-friendly, and sometimes lulls injured employees into a false sense of security. They may be asked to fill out a simple form describing their injuries and provide medical documentation to support their claim.

So why would a claim be denied? First, the terms of a long-term disability policy may exclude coverage in certain situations. Some Philadelphia long-term disability insurance only covers “any occupation” injuries. This means that the injured employee is not actually considered disabled unless they are unable to perform any type of income-producing work. For instance, an employee hurt at a construction site may not qualify for benefits if the company determines that they can perform a desk job.

Other policies, by contrast, are known as “own occupation” insurance. If the same construction worker cannot perform construction work but could still perform a desk job, they would be considered disabled because they could no longer work in their own occupation.

Another reason why a long-term disability claim might be denied is lack of proper medical documentation. Some employees get hurt but fail to seek all available medical treatment. The insurance company may deny the claim due to lack of a complete record.

Similarly, a treating physician should provide a medical opinion with a great degree of detail in order to substantiate your claim. Physicians often fail to provide a robust opinion, supported by records, which truly establishes the disability of the injured employee. The insurance company then rejects the claim for lack of proper medical documentation.

Steps To Take After A Denial

The denial of a long-term disability claim can be a traumatic and stressful event. Injured victims, who are already without an income, are now facing more time without receiving payments from their policy. With an uncertain future, you may wonder where to turn next.

Under the federal Employee Retirement Security Act (ERISA), long-term disability denials are subject to appeal. While ERISA permits a federal lawsuit to be filed in the event of a rejection of benefits, the law also requires claimants to exhaust all available “administrative remedies” prior to filing suit.

The “administrative remedies” are usually just internal appeals that are found within the policy itself. The language of your long-term disability contract contains information regarding your appeal rights. All injured employees should request a full copy of their policy before they begin the process of applying for long-term disability. Typically, the same company who denied your coverage the first time is the one deciding your appeal. The appeal may be a formal hearing where you can present evidence or it may an appeal where only written documentation is considered.

It is important to construct a strong appeal package to support your claims. This includes all pertinent medical information, information regarding your injuries, and how your injuries render you unable to hold employment in accordance with the definition of “disability” in your policy. Having an experienced long-term disability lawyer is vital pursuing a successful administrative appeal.

If your administrative appeal is denied, the next step is to file a federal ERISA lawsuit against the insurance company. The reviewing federal court will look at the actions taken by the insurance company in order to determine if they acted within a reasonable standard. The results of the federal court decision are typically the final step in the claims process.

A Philadelphia Long-Term Disability Attorney Can Help with Your Claim

It is estimated that about 25% of all long-term disability claims are denied. As many as 60% of these claims are never resubmitted following the initial denial. Employees who paid for their long-term disability insurance and who suffer injuries on the job are usually entitled to benefits. However, some insurance companies are notorious for not paying without a fight.

A skilled long-term disability lawyer will let the insurance company know that you are serious about your claim. Knowing your legal rights is invaluable in this situation. Injured employees should be prepared to pursue all applicable administrative rights. With the help of an attorney, most Philadelphia long-term disability claims can go from rejected to approved.