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Why Do Long Term Disability Claims Get Denied in NJ?

Long-term disability insurance offers a financial lifeline when an individual is unable to work because of a disabling condition. Despite their critical role, these claims often face denials for various reasons, leaving claimants in an unsettling position.

If your claim has been denied, do not worry. Our experienced team is here to help you appeal the decision and get the benefits you need. We will help you gather additional evidence to strengthen your case and can represent you at any hearings scheduled. Insurance companies will look for any reason to deny a claim, so it is unsurprising if one is denied because of a simple procedural error. In many cases, having an attorney on your side will be enough to keep the insurance company from playing games. If the denial is upheld, we can explore further options to get the compensation you deserve.

Call our New Jersey disability attorneys at Young, Marr, Mallis & Deane at (609) 755-3115 for a free case review.

Reasons Why Long-Term Disability Claims Get Denied in New Jersey

Long-term disability insurance policies are designed to replace a portion of your income if you become disabled and cannot work. Despite the clear benefits of these policies, many individuals find their claims denied for various reasons. When this happens, our Passaic, NJ disability lawyers will be waiting to help you fight the decision and get the benefits you need. More often than not, providing additional documentation will be enough to get your claim approved. However, some denials might be harder to fight.

Lack of Medical Evidence

When filing for long-term disability claims, it is crucial to provide sufficient medical evidence to support the claim. Insurance companies require extensive proof that the claimant’s medical condition is severe enough to prevent them from working. This typically includes detailed medical records, doctor’s notes, test results, treatment plans, and more.

The medical evidence should be comprehensive enough to convince the insurance provider that the claimant is genuinely unable to work because of their condition. Failing to provide sufficient and convincing medical evidence could lead to the denial of the claim. Therefore, you should work closely with your healthcare provider to ensure that all the required documentation is provided and accurately represents your medical condition.

Pre-existing Condition Exclusions

Long-term disability policies are meant to provide financial protection to individuals who are unable to work because of an injury or illness. However, many of these policies contain pre-existing condition exclusions. This means that if a disability arises from a condition that the claimant had before obtaining the policy, the insurance company might not cover the claim.

The specifics of these exclusions can vary greatly between policies. Some policies might have a look-back period, which means that the insurance company will review the claimant’s medical records for a certain period of time prior to the policy’s start date. If the claimant was diagnosed with a condition during this period, the insurance company might deny the claim.

Other policies might have a broader exclusion that applies to any condition the claimant had before obtaining the policy. Also, some policies might only exclude certain conditions, while others might exclude all pre-existing conditions.

To avoid any surprises, you should carefully review your policy’s terms and conditions. If you have any questions about the pre-existing condition exclusion or any other aspect of your policy, our team can answer them.

Failure to Meet the Policy’s Definition of Disability

Disability insurance policies come with varying definitions of disability. While some policies define disability as an inability to perform the duties of one’s own occupation, others require that the person be unable to perform the duties of any occupation. This means that if you are unable to perform the duties of your current job but can still perform the duties of another job, you might not qualify for disability benefits under some policies.

It is important to carefully review your policy’s specific definition of disability to ensure that you are covered in case of disability. Failure to meet your policy’s definition of disability might result in claim denial, so it is crucial to understand the terms and conditions of your policy before making a claim.

Procedural Errors

Filing for long-term disability typically involves intricate procedures and strict deadlines that can make the whole exercise quite complex. Failure to comply with these procedures and deadlines can result in a claim denial.

Some of the reasons why a claim can be denied include missing deadlines for filing claims or appeals, not providing requested information promptly, or failing to exhaust all internal appeals before filing a lawsuit. Therefore, it is essential to work with our firm to familiarize yourself with the procedures and deadlines that apply to your specific case to avoid any mistakes that can lead to a claim denial.

Non-compliance with Treatment

Insurance companies might also deny a claim if the claimant is not adhering to the prescribed treatment for their medical condition. The insurers expect the claimants to make reasonable efforts to recover from their disability, which includes following the treatment plans set out by their physicians.

This means that the claimant should attend all medical appointments, take medications as prescribed, and participate in any recommended therapies, such as physiotherapy or counseling sessions. If the claimant does not comply with the prescribed treatment, the insurer might view this as a lack of effort on the claimant’s part to recover and, therefore, deny the claim.

Surveillance and Social Media

When individuals file for disability claims with their insurance provider, they might not realize that their insurer could be watching them beyond just their medical records. Insurers often employ surveillance teams and scour social media to investigate the validity of a disability claim.

They might look for any evidence that contradicts the claimant’s reported limitations, such as photos or videos of the claimant engaging in physical activities or performing tasks that they claimed they were unable to do. This evidence might be used to deny the claim, as insurers consider it as proof that the claimant’s limitations might not be as severe as they initially reported.

What to Do if Your Long-Term Disability Claim Gets Denied in New Jersey

Understanding why your claim was denied is the first step toward formulating an effective appeal strategy. Your denial letter should provide specific reasons for the denial, like those listed above, and information about your right to appeal. Carefully reviewing this letter with your attorney will help identify any errors or inconsistencies that can be addressed in your appeal.

If your claim was denied because of insufficient medical evidence, gathering additional evidence can strengthen your appeal. This might include additional medical records, statements from your treating physicians, or even independent medical evaluations.

If your appeal is denied, you usually have the option to file a lawsuit in federal court.