You had surgery, or a serious diagnosis, and your short-term disability claim was approved. You have been getting checks for months. Your doctor still says you cannot work, and you may be getting worse. Then the short-term benefits run out, you apply for long-term disability, and the same insurance company says no.
How can one company agree that you are disabled and then decide you are not?
The answer is that short-term and long-term disability are different benefits, often with different rules, and the insurance company looks at your file again from the start. Here are five reasons an LTD claim is denied after STD approval, plus one more that is easy to fix.
1. The LTD policy may use different rules
Short-term disability generally covers an initial period when you cannot do your regular job. Long-term disability comes from a separate policy or separate plan provisions, and that policy may define “disabled” differently. It may also demand more detailed evidence of how your condition limits you.
Example: a warehouse employee has lumbar spine surgery. His STD claim is approved because he cannot lift, bend, or stand for long periods. When he applies for LTD, the insurance company asks a narrower question: do his medical records show those restrictions continue past the LTD elimination period? It decides they do not.
Your medical condition may be exactly the same. The rules the insurance company is applying may not be.
One caution: do not assume the insurer is already using the tougher “any occupation” test. Many LTD policies start with an “own occupation” definition and switch later, often after 24 months. Read your policy. More: Own occupation vs. any occupation.
2. Your records do not explain why you cannot work
This is the reason I would spend the most time on. A serious diagnosis is not enough. The insurance company wants evidence of how your condition affects your ability to do the duties of your occupation.
Your records may confirm degenerative disc disease and never say:
- how long you can sit,
- how long you can stand or walk,
- whether you need to lie down during the day,
- whether you can keep a regular work schedule, or
- whether pain affects your concentration.
Worse, treatment notes often say “patient doing well” or “condition stable.” The insurer reads those words as proof you can work. And a one-line note from your doctor saying you are “disabled” carries less weight than a detailed explanation of your restrictions.
Ask your treating physician to document specific limitations, with numbers, and to explain how each one interferes with your job. “Can sit 30 minutes at a time, must then stand and walk for 10 minutes” does work in a file. “Patient is disabled” does not.
3. The insurer thinks you have recovered enough to go back to work
STD claims are often approved after surgery, an acute injury, or the start of treatment for a serious condition. The insurance company may expect you to recover within a certain time. As your STD period ends, it reviews updated records and finds evidence that treatment worked.
Example: three months after cervical spine surgery, the surgeon writes that the operation was a success and pain has improved. The insurer treats that note as proof the claimant can return to work. But the claimant still has limited neck movement, arm weakness, ongoing pain, medication side effects, and cannot sit at a computer for long.
There is a big difference between getting better and getting well enough to work full time. Make sure your follow-up records say which limitations remain, even when treatment has helped.
4. The insurer’s doctor disagrees with your doctor
The insurance company may hire a physician to review your records. That doctor may never examine you or talk to you. Or the insurer may send you to an independent medical examination. Either way, the result is often an opinion that you can do your job, and the insurance company is not required to accept your treating physician’s opinion over its own reviewer’s.
Example: your orthopedic surgeon says you cannot sit for more than 30 minutes at a time and must change positions often. The insurer’s reviewing doctor reads your MRI and treatment notes and concludes you can do sedentary work.
Your surgeon may have seen you 15 times this year. The reviewer may never have met you. Get a copy of the review from your claim file and ask your treating physician to answer each inaccurate assumption in it. More: What to expect at an IME.
5. The insurer misunderstands your occupation
Sometimes the dispute is not about your health. It is about what your job requires.
LTD insurers often evaluate your occupation as it is generally performed, not the specific job you did for your employer. Some policies say so expressly. The insurer may rely on an occupational database or a vocational consultant and classify your work as sedentary even though your real job was physical.
Example: a sales manager drives long hours, visits customer sites, and walks warehouse floors. The insurer classifies “sales manager” as mostly desk work and decides that, despite serious walking and driving restrictions, the claimant can still do the occupation.
Compare the insurer’s description of your occupation with your policy’s definition of disability and with what you actually did. A statement from a former supervisor describing your real duties can help.
Bonus: the insurer may be missing records
Before you assume the insurance company reviewed everything, find out exactly what it reviewed. Specialist reports, imaging, or test results may never have arrived. Your doctor may not have returned a questionnaire. The records may be months old. A denial based on an incomplete file can be challenged with the missing evidence.
What to do now
- Get your LTD policy and your denial letter. Find the definition of disability and the exact reasons for denial.
- Request your complete claim file. For ERISA claims, you are entitled to it free of charge. Look for the medical and vocational reviews and for missing records.
- Strengthen your medical evidence. Ask your doctors to answer the insurer’s specific reasons, focusing on whether you can keep up the duties of your occupation day after day.
- Talk to a lawyer before you file your appeal. If your plan is governed by ERISA, you generally have at least 180 days to appeal, and the appeal is usually your last chance to add evidence. If you later sue, the court may look only at that record.
One of the biggest mistakes you can make is filing a quick appeal that says, “My doctor says I’m disabled.” A successful appeal shows exactly why the insurance company is wrong and puts the medical and vocational evidence in the file to prove it.
CTA: Approved for STD and denied LTD? Call 770-351-0801 or request a free case evaluation. Don’t wait until your appeal deadline is close to get help.
Related: Top 5 reasons LTD claims are denied · Recently denied? · Should I appeal myself or hire a lawyer?