If the insurance company denies your application for long-term disability benefits, don’t give up hope – you may still be able to recover benefits by way of an appeal. A denial of long-term disability (“LTD”) benefits is only justified if you do not qualify for those benefits. If there has been a denial of your application for long-term disability benefits, this post will be of interest to you as it sets out common reasons that legitimate claims are denied, discusses some of the steps you should take to begin the appeal process, and explains how a lawyer with experience handling long-term disability claims (Calgary-based Ludwar Law Firm, for example) can help you navigate the appeal process.
Reasons that legitimate long-term disability claims are denied
Many legitimate long-term disability claims are denied simply because the LTD benefit application did not provide sufficient information or medical documentation. A successful appeal may require you to submit a more detailed medical opinion from your doctor that explains your functional limitations (in other words, the ways in which your illness or injuries restrict you in the performance of your job). Here are some other common reasons that an application for long-term disability may be denied:
Long-term disability claims are frequently denied because the specific condition the claimant is suffering from is difficult to pin down or prove – for example, depression, fibromyalgia, Chronic Fatigue Syndrome, chronic pain, memory and concentration problems, headaches, and Post-Traumatic Stress Disorder. Some of those diagnoses are seen as “controversial” or not taken seriously by insurance companies. It is important to understand that you don't need to have a specific diagnosis to "prove" your disability; you only need to show that you cannot work. https://www.yourdisabilitylawyer.ca/areas-of-practice/long-term-disability-claims
Legitimate long-term disability benefit applications may be rejected based on how the insurance company interprets or applies the insurance policy – but the insurance company’s interpretation is not always correct. For example:
The insurance company may deny your claim by taking the position that you are not disabled as the term is defined in the policy (e.g., by saying that you still have the ability to do jobs that are similar to your own, or that you still have the ability to perform some parts of your former job).
With the more difficult to prove conditions such as fibromyalgia, chronic pain, or Chronic Fatigue Syndrome, the insurance company may deny your claim because they consider you to be “able to work” since you are sometimes able to perform all or parts of your former job (even though you may be unable to show up for work reliably).
The insurance company may point to a policy exclusion such as a pre-existing condition as the basis for its denial, but such a condition may not be relevant to your current status (e.g., if pre-existing condition was asymptomatic for a long period).
Understanding the reason or reasons for the denial of your long-term disability claim is essential to the appeal process, as your appeal should address each of the insurance company’s reason with new information or updated medical documents.
Steps to take after your long-term disability claim is denied
After receiving a denial from the insurance company, you will need to take several steps, including these basics:
Get the denial in writing from the insurance company if you were not provided with a denial letter.
Determine the deadline for appealing the decision. There are very important limitation periods that will apply for any appeal or review, and you cannot miss them or your claim be denied by the insurance company on a final basis. In addition, it is important to note that there are separate deadlines to commence a lawsuit so you must ensure that you do not miss those limitation periods while going through any internal or administrative appeal options.
Gather documents and medical information to support your appeal (for example, an updated medical opinion from your doctor that addresses the insurance company’s reasons for denial). The evidence you submit with your appeal should challenge each reason for the denial of your long-term disability claim.
Look at your appeal options and decide which is best for you. Options may include an internal appeal or administrative review, appeal hearing or arbitration (if your workplace is unionized), and/or commencing litigation. The reason for the denial of the long-term disability claim may inform the option you choose. In some cases, it is best to go through the internal review process first before bringing a lawsuit (if necessary). In other cases, it may be best to commence a lawsuit immediately instead of exhausting the insurance company’s internal appeal process.
You should also seriously consider talking to a lawyer who specializes in long-term disability claims. Calgary-based Ludwar Law Firm focuses on helping clients with long-term disability claims and can help you appeal the decision to deny your claim for long-term disability benefits. The next section will discuss some of the ways that an experienced long-term disability claims lawyer can help you.
How a Calgary long-term disability lawyer can help your appeal
It is strongly recommended that you consult a lawyer with expertise in long-term disability claims appeals as early on in the process as possible – ideally, as soon as you receive the denial letter from the insurance company. An experienced long-term disability lawyer can help you through the appeals process in ways that include:
· Identifying deadlines and ensuring they are met.
· Evaluating the strength of your claim for long-term disability benefits and the likelihood of success of an appeal.
· Using knowledge of the appeal process and policies particular to specific insurance companies to maximize your chances of a successful appeal.
· Helping you build evidence where denial is based on the insurance company’s opinion that your symptoms were not properly "proven" or that functional limitations are not clearly explained.
· By commencing litigation if necessary and advising you on whether you may qualify for bad faith or aggravated damage awards in your lawsuit.
Advice on bringing an appealing long-term disability claims
Calgary-based Ludwar Law Firm is focused on providing clear advice and practical solutions to clients with long-term disability claims. Whether you are considering making an application for long-term disability benefits, have already started the process of making a disability claim, or are faced with a denial of your claim, we are here to help. Our Calgary long-term disability claims lawyer knows to get your insurance company to look at your disability evidence again. To schedule a free initial consultation, call us today at 403-670-0055 or contact us using our eForm.