Why Would Long-Term Disability Be Denied?

Long-term disability insurance companies could deny your claim for a variety of reasons. A frequent reason is because your claim is excluded by a pre-existing condition, which will be discussed at length below.

You must be mindful that you bear the burden of proving your disability claim. The long-term disability insurance application may require forms to be completed by you, your employer, and your doctor. The insurance company is under strict deadlines under ERISA (Employee Retirement Income Security Act) to process a disability claim, and they often deny claims for failure to receive the required paperwork or medical records in support of your claim. Pond Lehocky Giordano encourages you to send information to the insurance company in a way where you receive a receipt, such as by fax, email, or certified mail. Never just mail something to the insurance company – always make sure you have a receipt.

Most long-term disability insurance policies provide that the insurance company has the discretionary authority to interpret the terms of the policy and make factual determinations in a claim. If the policy provides this language, a Federal Court must give deference to the insurance company’s decision on your claim and will only overrule their determination if you can prove that the insurance company’s decision was arbitrary or capricious.

Black’s Law Dictionary defines “arbitrary and capricious” as “[a] willful and unreasonable action without consideration or in disregard of facts or law.” Admittedly, this is a tough burden for the challenger. So, if your employer-provided long-term disability insurance policy provides that the insurance company has the discretionary authority to interpret the terms of the policy and make factual determinations in your case, they get to decide which doctors are credible between the doctors they hired or your doctor who has examined you. They can also decide whether your symptoms are credible.

A court will not disturb those conclusions unless you can show that the insurance company’s decision was arbitrary or capricious. That gives enormous authority to an insurance company to act as the judge and jury of your claim and to decide whether they must pay you long-term disability benefits. You should never fight a long-term disability insurance company on your own. Please contact us for a free consultation.

Can long-term disability be denied for pre-existing conditions?

Long-term disability insurance companies often deny claims based upon a pre-existing condition exclusion to the employer-provided insurance policy. The policy will define what a pre-existing condition is.

In most cases, the policy will have a “look back period,” which is a period prior to the effective date of coverage in which the insurance company will analyze whether you had any treatment, sought medical advice, or had diagnostic testing for a condition. If you had any treatment for a condition in a look back period, the insurance company will deny coverage for any disability related to that condition. In some policies, the insurance company may have such a broad definition of a pre-existing condition that it will extend the exclusion to anything that derives from the pre-existing condition.

For example: Client A begins working for his employer on November 1, 2020. His insurance becomes effective the following month, in December 2020. The policy provides for a look back period of 3 months prior to the effective date of coverage. Client A was treated by a doctor for neck pain in September of 2020 – he simply complained of pain, and the doctor gave him a muscle relaxer.

Client A works for his employer until May of 2021, when his neck pain becomes so bad that he must stop working. His doctor sends him for an MRI, and it shows that he has a disc herniation and needs spinal surgery. In this situation, the employer-provided long-term disability insurance company will likely deny any disability benefits because Client A was treated for neck pain during the look back period.

Contact Pond Lehocky Giordano for more information.

If your claim has been denied based upon the pre-existing condition clause to your employer-provided long-term disability policy, please contact us for a free consultation. We would be happy to help you with your claim.