When a long-term disability claim is denied, the letter usually gives a reason in insurance language: “insufficient medical evidence,” “does not meet the definition of disability,” “capable of sedentary work.” Each of those phrases points to a specific gap the insurance company believes is in your file. Once you know which gap it is, you know what your appeal has to fill.
Here are five of the most common reasons insurers give, and what to do about each one.
1. The medical evidence shows a diagnosis, not an inability to work
This is the most common problem. The insurance company does not dispute that you have a serious condition. It says your records do not show that the condition keeps you from working.
That usually happens because medical records are written to treat you, not to prove a disability claim. Your doctor writes “stable” or “doing well” because you are doing well compared to last month, not because you can work 40 hours a week. The records list diagnoses but never say how long you can sit or how often you need to lie down. There may be no objective testing, or there may be gaps in treatment.
Here is an example. A claimant with degenerative disc disease reports severe back pain. Her doctor’s notes, visit after visit, record normal strength, a normal gait, and no neurological deficits. The insurance company reads those notes and concludes that nothing in the file proves she cannot work.
How to answer it: get a detailed statement from your treating physician that explains your functional limitations with numbers. For example: “She can sit for about 20 minutes at a time, for a total of about 2 hours in an 8-hour day. She needs to lie down for 30 to 60 minutes twice a day. Her pain and medication side effects will cause her to miss more than three days of work a month.” The statement should also explain why, by tying each limitation to the findings in the records.
2. You do not meet the policy’s definition of disability
LTD eligibility depends on the words of your policy, not on Social Security’s rules. Most group policies use one or both of these tests:
- Own occupation: you cannot perform the material duties of your regular occupation.
- Any occupation: you cannot perform any occupation that fits your education, training, and experience, sometimes only jobs that pay a set percentage of your old earnings.
Many policies switch from the first test to the second after 24 months of benefits.
Example: a 58-year-old accountant develops cognitive problems and can no longer do complex financial analysis. The insurance company agrees he cannot work as an accountant but says he can do simpler clerical work.
How to answer it: read the exact definition in your policy, including any earnings requirement. Then develop vocational evidence showing why your limitations rule out the jobs the insurance company named. More: Own occupation vs. any occupation.
3. The insurance company’s doctor disagrees with yours
Insurance companies routinely hire physicians to review files. Many of these reviewing doctors never examine you or speak to you. They often conclude that the records do not support your doctor’s restrictions, that your symptoms do not match the test results, or that you can do sedentary work. Some insurers also order an independent medical examination or a functional capacity evaluation.
Example: a treating neurologist concludes that a patient’s multiple sclerosis causes disabling fatigue and cognitive problems. A reviewing physician hired by the insurance company reads the same records and says the patient can work full time at a desk.
How to answer it: get the reviewing doctor’s report from your claim file, then ask your treating physician to respond to it point by point. The response should name the evidence the reviewer overlooked and explain why a doctor who has treated you for two years is in a better position to judge your limitations than one who has read your chart for an afternoon.
4. A policy exclusion or limitation applies
Some denials have nothing to do with how sick you are. They turn on a clause in the policy, such as:
- Pre-existing conditions: a condition treated during a set period before your coverage began may be excluded for a time.
- Mental health limitations: many group policies limit benefits for certain psychiatric conditions to 24 months.
- Self-reported symptoms: some policies limit benefits for conditions diagnosed mainly from your own reports of symptoms.
- Substance-related conditions: some policies exclude or limit these.
Example: a claimant receives benefits for severe depression and anxiety. At 24 months, the insurance company stops paying under the mental health limitation, even though she still cannot work.
How to answer it: find the exact clause the insurance company relied on and read it yourself. Then ask whether another condition, such as a back problem, heart condition, or neurological problem, keeps you from working on its own. If it does, the limitation may not end your claim. More: The 24-month mental health limitation.
5. Paperwork problems, inconsistencies, and failure to cooperate
Even a strong claim can be denied for administrative reasons: a missed deadline, records that were never sent, a skipped insurer exam, or forms that describe your limits differently from one month to the next. Surveillance video and social media posts fall in this category too.
Example: a claimant writes on her forms that she cannot sit for more than 20 minutes. An investigator films her driving for over an hour. The video does not prove she can work full time, but the insurance company will use it to question everything else she has said.
How to answer it: describe your limits accurately and consistently, including your good days and your bad days. Keep your treatment regular, answer the insurance company’s requests on time, and address any inconsistency head-on in your appeal instead of hoping it goes unnoticed.
What all five have in common
Each reason for denial can be answered with evidence, but only if the evidence goes into your file before the insurance company makes its final decision. If your coverage comes through your employer, ERISA rules give you at least 180 days to appeal, and in most cases the appeal is your last chance to add evidence. Do not spend it on a one-page letter that says you disagree. More: Recently denied? 3 critical steps.
CTA: Was your LTD claim denied for one of these reasons? Call 770-351-0801 or request a free case evaluation. We will tell you what your appeal needs to say.