How to Appeal a Long-Term Disability Denial

January 24, 2024 by

Receiving a disability denial letter can be discouraging, especially when you’re trying to recuperate. The denial means you’ll have to deal with the insurer to find out why and what to do next. The letter will explain why your claim was denied, that you have the right to appeal, and include a deadline by which you must file that appeal. These deadlines are strict, so don’t ignore them, or your claim will be denied.

long term disability denial

Do not be discouraged if you receive a denial letter. Long-term disability claims can be complex, so enlisting the help of a Houston disability attorney can make the process easier and increase your chances for approval.

The Appeals Process

With most insurers, you’ll need to go through the appeals process before you can file any legal action like a lawsuit. Appeals give the insurance company another chance to review your claim and any additional information they did not review before.

The insurer may also request additional information from you, including additional medical records. They may also request an independent medical examination from their doctor, or a functional capacity evaluation to determine if they can work at any job.

In many cases, insurance companies issue more than one denial, but you still have an opportunity to appeal a second time. Once again, you’ll receive a strict deadline by which you must file your appeal, so make sure you submit your appeal timely.

Additional Documentation

Your first step is to request a copy of your claims file from the insurer. You’ll see what the company is working with, and what you need to do to file your appeal. If you have already enlisted the help of a Houston disability attorney, they can help in getting your copy of the file.

Your file should contain as much information as you need to support your claim and show that your condition warrants long-term disability. This can include:

• Medical reports from your medical providers, such as your primary care physician, along with any specialists who are involved in your care and treatment.

• Letters of support from your healthcare providers, vocational evaluation experts, and others directly involved in your claim.

• Information that clarifies or further explains anything that was overlooked or not correctly determined in the denial

• Any other information that clears up any legal mistakes or other misunderstandings that led to the denial of your claim

Once you’ve completed your due diligence and gathered additional information, work with your disability attorney to begin your appeal. You may need additional information, and your attorney can help you obtain the rest for your claim, and then draft your letter of appeal.

When Can I Sue?

If your long-term insurance is employer-provided, you’ll need to go through the entire appeals process first. After you’ve exhausted all your appeals rights, you can then file a lawsuit under ERISA (Employment Retirement Income Security Act.) However, if you bought your policy yourself, the policy is regulated by insurance laws in the State of Texas.

The evidence submitted for your claim and appeals will become part of the lawsuit.

When you’ve decided to pursue litigation, work with an attorney who has experience with disability claims and understands the process.

Your Houston LTD Disability Attorney

If you need help filing a long-term disability claim or are having trouble with the insurer paying your benefits, we’re here to help.

We’ve helped over 4,000 Houstonians receive the LTD benefits they need. The Herren Law Firm can help you with your application, appeals and help you through the process, and give you one less thing to worry about. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation and no up-front fees. We only collect a fee if we win your case.

Filed Under: Long Term Disability Tagged With: , ,

Reasons For Long Term Disability Denial Of Claim

March 3, 2020 by

After paying premiums for several years, you expect that when you have to file a claim for long-term disability your insurance company will take care of you. But as many policyholders have discovered, that’s not always the case. You’ve had doctor visits, testing, treatments, therapy, and filled out a ream of paperwork that they’ve asked for, only to see your claim denied. So what’s going on here?

Reasons For Long Term Disability Denial Of Claim

Insurance companies are in business to make money and will deny your claims any way they can. These are some of the reasons your claim may have been denied.

They’re Watching You

Insurance companies regularly conduct video surveillance of individuals who file an LTD claim when they say they’re disabled and can’t work. Why? To prevent obvious insurance fraud, particularly by individuals who claim they can’t work because of an injury, but they’re publicly engaged in activities that they shouldn’t be.

Surveillance can be both long-range video and social media investigation. Even with your account set to “private,” it’s highly possible your vacation pictures and other “action shots” can be visible to people who you never intended. It’s always advisable to set your posts to “friends only,” but you should also be aware of who is following you and who you accept friend/follow requests from. Additionally, investigators may be able to access your account by demanding your passwords.

For instance, if you’ve filed a claim for a back injury that prevents you from working, and you post pictures of yourself surfing in Maui, that’s a clear indication that you’re not injured. Of course, if that picture is five years old, an investigator may not realize that, even if you date it.

Best bet: limit your social media postings, or deactivate or delete them until your case is decided.

Not Enough Medical Evidence

Any kind of insurance claim needs sufficient medical evidence to support it. Evidence is key to supporting your claim and showing that you are, indeed, disabled.

  • Consistent medical treatment for your condition(s). Your insurer expects that you are receiving consistent and regular medical care for the condition you are claiming. If you aren’t receiving regular medical care, the insurer will interpret this as your condition isn’t serious. Physical illnesses will include physician visits, as well as any required testing such as X-Rays and MRIs. If your claim includes mental illness such as depression, you should be seeing a mental health provider (such as a psychologist or psychiatrist) on a monthly basis or better.
  • A doctor’s statement detailing your medical condition and how your disability limits your ability to work. Don’t rely on the insurance company’s forms—they are designed for you to respond in a way that will ensure your claim is denied. Should your doctor deny you support for your disability, find another one who will help.
  • Absent medical records that are essential to proving your claim. If the insurance company hasn’t requested all relevant records, request a list of all the records they have already requested an a list of what they’ve received. Then insist that the insurer request all the records on the list. You may have to be persistent until they have all of your medical records.

Missed Deadlines

Insurance companies are notorious for deadlines, and even one day can end your claim. Make sure you understand their deadlines for both applications and appeals.

You Don’t Meet Their Definition Of “Disabled”

As ridiculous as this may sound, most policies have strict definitions of what “disabled” actually means.

One of the biggest sticking points is “own occupation” and “any occupation” clauses in the policy.

“Own occupation” indicates that your disability prevents you from fulfilling the requirements of your current occupation. “Any occupation” means that you are unable to fulfill the requirements of any occupations. Some policies begin as “own occupation” but transition to “any occupation” after 24 months.

Additionally, pre-existing conditions and medical conditions related to current or prior substance abuse tend to be excluded. Mental conditions and those that are based primarily on self-reported symptoms, such as fibromyalgia and chronic fatigue syndrome, may be limited to 24 months of benefits after approval.

Your Houston LTD Disability Attorney

When applying for long-term disability it’s important to follow your insurer’s instructions to the letter. They’re not interested in helping you and your claim, but there’s someone who can help.  The Herren Law Firm can help you with your application, appeals and help you through the process so you can get the benefits you need. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation, and no up-front fees, because we will only collect if we win your case.

Filed Under: Long Term Disability Tagged With: , ,

Long Term Disability Death Benefits In Houston, TX

September 16, 2019 by

It’s difficult enough when you or a family member has to apply for long-term disability, especially if there is a terminal or progressive, degenerative illness, such as ALS, or an injury that will never heal. What’s even more difficult to think about is when the time comes that you or your loved one passes away.

But when the day comes, will you receive any death benefits from the LTD policy? This will depend on the terms of the policy, which should be reviewed completely before attempting to apply for LTD disability benefits.

Long Term Disability Death Benefits In Houston, TX

What Is A Death Benefit?

This is a lump sum paid to an insured’s family when the individual dies, and is most commonly associated with life insurance. In fact, life insurance is just that—insurance on someone’s life, which pays out to whomever the insured assigns as a beneficiary.

But with long-term disability, there may or may not be a “death benefit.” Some policies do offer a “survivor benefit” that pays a lump sum of LTD death benefits to survivors for a specific time period, usually one to three months. But as a rule, if the individual has passed away, there is no more need for the insurer to make payments, so they will stop.

If your LTD policy comes through your employer, it may or may not include a death benefit—check your policy. You may have been offered a rider for an additional charge to have that would provide your family or other selected beneficiaries a death benefit.

You may have selected this option for your own LTD policy as well. Again, read and check your policy to be sure, or contact your agent to clarify. You may have the option of adding this type of LTD death benefits, even if you’ve had your policy for some time.

An Alternative LTD: Accelerated Death Benefit

If your LTD insurance is not sufficient, or you are terminally ill and need help immediately, one possibility would be to request an accelerated death benefit on your life insurance policy. There are restrictions on requesting this benefit, and it will reduce the death benefit (total sum of money) paid to your survivors after you die.

You may also use this coverage if you are confined to a nursing home, or are deemed terminally ill. Some policies automatically pay this in circumstances of an imminent death. To qualify, you will have to be certified by a doctor or other medical professional that you are terminally ill, and that death is expected in 12 to 24 months. Some providers set the threshold at six months.

Critical illnesses that can also trigger this benefit include:

  • Stroke
  • Cancer
  • Heart attack
  • Kidney failure
  • Organ transplants
  • ALS

Chronic illnesses are not the same as critical illnesses. To determine if your policy allows an accelerated death benefit for your illness, as always, review your policy and speak with your insurance agent to be sure.

Your Houston LTD Disability Attorney

Long term disability can be an annoying process before you begin receiving benefits. The Herren Law Firm can help you with your application, appeals and help you through the process, and give you and your family peace of mind. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation, and no up-front fees, because we will only collect if we win your case.

Filed Under: Long Term Disability Tagged With: , ,

Overview of Long Term Disability Policy Age Limits

May 6, 2019 by

The average length of a disability that keeps people from working is about three years, and depends on the type of disability they have and their age. As recoveries go, a person in their mid-twenties usually recovers from a disabling illness or injury faster than a person in their mid-fifties or sixties. But depending on the type of policy you have, long-term disability (LTD) may last six months, a year, or longer. Will it last long enough?

houston disability lawyer

What Type Of Policy Do You Have?

There are two types of policy coverages.

  • Your policy may cover you for “any occupation,” meaning that you’re covered as long as you can’t work any job doing anything, whether or not it’s related to your current job and/or vocation, for the same or less money.
  • Your policy covers you for “own occupation,” meaning that you’re covered as long as you can’t perform your current occupation. Whether you can perform another occupation for which you’re qualified isn’t a determining factor.

Some policies combine the two, with “own occupation” for the first two years, and “any occupation” after that. Other policies offer a cost of living increase as an optional benefit that may cost more.

How Long Do LTD Benefits Last?

Most group LTD policies last until age 65, or until your actual retirement age. The presumption is that once you’re retired, you no longer need the income from your employment.

Most people assume they will retire at 65, but SSA has changed retirement ages for different individuals. Currently, individuals born in 1955 or later can retire at age 66 and 2 months. If you were born after 1960, your retirement age is 67.

Look for LTD benefits to end, with some exceptions, at your time and age of retirement.

Benefits Beyond 65

Purchasing a long-term disability policy with a benefit period longer than five years is more expensive, but comes with an additional benefit. You can choose a “lifetime” benefit period that will pay you as long as your disabled, even after retirement age, as long as you were disabled before the age of 60. This will be especially helpful if your disability is expected to last for many years, or is considered permanent.

These kinds of policies tend to be much more expensive, and could be harder to find. If you’re unable to get one, at least purchase a policy that will pay you until your legal retirement age. With an employer’s policy, your status will automatically change to “retired” once you reach that retirement age bracket.

Most LTD policies pay 60% to 70% of your regular salary and none will pay 100%. Different policies have different exclusions and restrictions.

Some policies have “level premiums,” which stay the same for the life of the policy. This is useful

Additional information, and a checklist for buying a policy, is available at the Consumer Federation of America’s website.

Houston Disability Lawyer Can Help With Your LTD Claims

Our Houston disability lawyer William Herren is experienced in handling all types of disability applications and claims including LTD claims, and our law office has helped more than 4,000 Houstonians, too. Call The Herren Law Firm today at 713-682-8194 (or use our online contact form) to schedule your free consultation with one of our disability attorneys. There’s no obligation. There are no up-front charges, because we’ll take your case on a contingency fee basis. You only owe us a fee when we win your case.

 

Filed Under: Long Term Disability Tagged With: , ,
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