Five Common Reasons Insurers Deny or Terminate LTD Benefits

Navigating the complexities of long-term disability or LTD insurance can be a daunting task, especially when you find yourself facing denial or termination of your benefits. Understanding the common reasons behind these decisions is crucial for claimants to assert their rights and seek the support they need.

Here are five of the more common reasons are insurer will justify denying or terminating your benefits: 

1. Inadequate Medical Evidence:

One of the primary reasons for denied or terminated LTD benefits is insufficient or inadequate medical evidence. Insurance companies require medical documentation to substantiate the claimant’s disability. Incomplete medical records, vague diagnoses, or inadequate supporting documentation can lead to a rejection of the claim. Frustratingly, insurers will often rely on this basis to deny or terminate your claim without specifics as to the reasons they deem the medical insufficient. Further, insurers will not provide you guidance on what information they feel you can or should provide to further your claim. Lastly, the insurer may claim you lack sufficient documentation when no such document or form exists. Lastly, the insurer may simply be incorrect that the records or forms already provided aren’t sufficient. It is often the case that a denial or termination on this basis is merely a boilerplate denial. 

2. Failure to Meet the Definition of Disability:

LTD policies typically have specific criteria for what qualifies as a disability. If the claimant’s condition does not align with the policy’s definition, insurers may deny the claim. Even in cases where an individual has a qualifying illness/injury, and medical documentation supporting same, the insurer can simply disagree that the condition is severe enough to justify a workplace disability. In this sense, you are at the mercy of an insurance company to make a subjective determination to deny your claim. It’s essential for individuals to seek out a careful review by a qualified lawyer, to understand the terms of their policy to ensure their condition meets the required criteria. Or pursue a legal claim to compel the insurer to pay a claim that meets their criteria despite their claim otherwise.

3. Missed Deadlines:

Strict deadlines may govern the filing of LTD claims and appeals – and eventually lawsuits. Missing these deadlines can result in an automatic denial. Keeping track of these timelines is confusing, and seeking legal advice promptly is recommended to ensure compliance. In addition, the deadlines cited by insurers for claims or appeals can be inconsistent with the law, and your legal rights to pursue a claim. Even more sinister are insurers who take weeks and months reviewing your claim – or further medical documentation they requested – only to later claim the delay (which they have caused) now leaves your legal claim out of time. It is crucial to seek advice as soon as possible where an alleged missed deadline is the reason provided for your claim denial. You are not legally required to appeal or denial, or wait until the insurer makes a final decision on your claim to pursue legal advice, or initiate a legal claim.  It is often the time between when the insurer denies your claim, and a legal claim in pursued, where claimants run into issues with deadlines, so it is imperative to act promptly.

4. Inconsistencies in Medical Records:

Inconsistencies in medical records, or conflicting information between different healthcare providers, can raise so-called “red flags” for insurers. However, inconsistencies in your medical records are common, often easily explained, or simply an oversight by your medical provider. While it’s essential to maintain clear and consistent communication among healthcare professionals to avoid potential issues, these inconsistencies are often beyond your control. The insurer may rely on any perceived inconsistencies to unfairly cast doubt as to the veracity of your claim.

5. Failure to Follow Treatment Plans:

Insurers may deny claims if claimants fail to adhere to prescribed treatment plans. It’s crucial to communicate openly with healthcare providers about any challenges in following treatment recommendations and to document these discussions. You may have good reasons for not wanting to, or being able to, pursue various treatments prescribed, or even discussed, with your various health care professionals. These can include cost, accessibility or availability of treatment, or the risks and side effects associated with a given treatment. Insurers will very often view treatment suggestions as absolute and/or mandatory, and failure to follow one or more of these treatments as a basis to deny paying your claim.

Understanding these common pitfalls is the first step in protecting your rights. When faced with denial or termination of LTD benefits, seeking the expertise of a legal professional can be a life changing decision. Please contact us today to answer these or any other questions.