Putting Your Best Claim Forward: Is Your Long-Term Disability Application Going to Be Denied?

The McKennon Law Group PC periodically publishes articles on its Insurance Litigation and Disability Insurance News blogs that deal with frequently asked questions in insurance bad faith, life insurance, long term disability insurance, annuities, accidental death insurance, ERISA and other areas of law.  To speak with a highly skilled Los Angeles long-term disability insurance lawyer at the McKennon Law Group PC, call (949)387-9595 for a free consultation or go to our website at  www.mckennonlawgroup.com  and complete our free consultation form today.

Disability insurance may be the most important type of insurance you can buy.  Why? Because it protects your income earning ability if you become disabled.  It can provide you with a substitute income when, due to injury or illness, you become disabled and can no longer earn a living.  Under most policies and under California law, you are considered “disabled” when you can no longer perform the substantial and material duties of your “own occupation” in the usual and customary manner and with reasonable continuity.  If the long-term disability insurance plan is employer-sponsored, it is likely governed by the Employment Retirement Income Security Act of 1974 (“ERISA”).  Under ERISA governed plans, you can ensure that you put your best claim forward by providing strong support to your insurance claims administrator.  This blog article briefly outlines the support you can provide, which may prevent your long-term disability claim from being denied.  That support includes strong medical evidence in support of your disability, sufficient evidence of your occupational responsibilities and consistent behavior reflected in your daily activities and on social media.

Obtain the Necessary Disability Forms and Complete Them Accurately

Your first step after deciding to file a long-term disability insurance claim is to obtain the necessary forms from your insurer and/or your employer.  Make sure you carefully complete these forms making sure they are honest, accurate and not overstated.

Strong Medical Evidence for Your Disability

While the specific type of medical evidence you need depends on the circumstances of your physical or psychiatric disability, your claims administrator will need to see that you are under the care of a doctor or mental health provider for your condition who has the requisite expertise in your disabling medical condition(s).  Additionally, to the extent you can, you should support your claim with “objective” medical evidence, in the form of X-rays, MRIs, CTs and blood work where possible.  While you do need to support your claim with sufficient medical evidence, this can also come in the form of medication and medical records, physician completed forms provided by the insurer, diagnostic records and letters from your physicians.  Frequently overlooked, medication records can work to provide additional medical support for your claim in two ways.  First, medications, such as those for pain management, can provide additional direct evidence in support of your disability (such as ongoing pain).  Second, such medications often have side effects, such as impaired concentration, that can also inhibit your ability to perform your occupation.

In addition to direct evidence of your ongoing, regular treatment, you should request statements from your regular treating physicians in support of your disability.  Your physicians should provide detailed statements as to your physical limitations, which will support your claim by explaining how your medical condition(s) cause your restrictions and limitations that prevent you from performing your occupation.  Additionally, your doctors should continue to support your disability throughout the claim investigation process.  For example, some administrators request a “peer review” of your records by a doctor or nurse hired to review your claim.  In this peer review, another medical professional reviews your medical records and other supporting evidence in your claim file, usually on paper although sometimes they can request an in-person medical examination.  As part of the peer reviewer’s assessment of your claim, he or she may contact your primary treating physician and ask him or her additional questions about your disability.  If this happens, you want to be sure that you have a treating doctor that strongly supports your claim.

Sufficient Evidence of Your Occupational Responsibilities

Although you need to check your specific plan’s definition of disability, it often relies on your inability to perform your “own occupation” or, after a certain period of time, “any occupation” for which you are qualified by education, training, or experience.  Often, the claims administrator fails to take into account the specific requirements of your particular occupation, given your level of education, training and experience.  Although often overlooked, you can easily request and provide your job description from your employer.  Then, there can be no mistaking the requirements of your position.  You should buttress your employer’s job description as necessary to assist you in asserting your disability.

Line Up Your Evidence in Support

Determine what other evidence you have to support your disability claim.  Do you have witnesses who can support it?  If so, get letters or statements from them.  Do you have a disability placard from the Department of Motor Vehicles?  If so, that may be relevant and you should submit it.  Do you have photographs of your home or apartment that show devices you have installed to assist you with your disability?  If so, you should submit them.  You should think about what evidence exists that will support your disability claim and if it will support your claim, submit it to the insurer.

Surveillance and Social Media Consistent with Your Restrictions?

When you file a “proof of claim,” your insurer begins gathering information, typically referred to as an “investigation” pursuant to its duty to fully investigate all insurance claims.  The information your insurer collects will include some of the information discussed above, such as medical records, pharmacy records and even a job description.  However, to further investigate the sufficiency of your claim, some insurers may request surveillance or may review your social media.  Surveillance may include more traditional “Sherlockian” investigations, such as undercover video surveillance (i.e., an undercover video recording of the insured’s daily activities for a certain period of time).  Also, given the rise in the use of social media, it may also include a review of your social media activities.  You should, if possible, discontinue or greatly reduce your use of social media.

Given the likelihood of surveillance, it is important that you conduct yourself in a way that is consistent with your restrictions.  While some disabilities allow for intermittent periods of activity that may otherwise seem inconsistent, it is important for you to at least be mindful of the potential for such surveillance.  As to social media surveillance, the same general principle applies, but please see our detailed article providing best practices in social media for those currently in evaluation for a long-term disability claim.

In addition to the detailed support you can provide, it is also important that you be mindful of the strict deadlines that apply to employer-sponsored ERISA long-term disability claims.  Overall, providing the insurance claims administrator with sufficient and timely evidence to support your disability is integral to the success of your claim and having an experienced disability, health and life insurance attorney can make all the difference.

Consult an Experienced Attorney

If your claim is complicated, you may wish to consult an experienced lawyer how handles disability insurance claims and litigation, like the attorneys of the McKennon Law Group PC.  We provide consultation services before and during your claim submission to make sure you are putting your best claim forward.  

If you wish to consult us regarding the filing of your claim for health, life, short-term disability or long-term disability insurance or if your claim has been denied, you can call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA insurance claims.

Share This Article

facebooktwittergoogle_plusredditpinterestlinkedinmail

Comments are closed.