If you have been diagnosed with a serious medical condition and cannot work, you may be able to file for long-term disability (LTD) benefits. While every policy is different, LTD insurance typically pays a wage loss benefit as long as you are disabled (or until retirement age). Because of the high value of these policies, insurance companies try to avoid paying LTD benefits. Claims examiners look for reasons to deny ERISA LTD applications. These “red flags” often involve credibility issues. While some red flags are unavoidable, you can minimize your LTD application’s red flags.
What Mistakes Should I Avoid in an ERISA LTD Application?
Do Not Overstate Your Symptoms
Insurance claims examiners are looking for reasons to deny your LTD application. Any doubt as to your credibility can result in a denial of benefits. For this reason, it is very important that you honestly report your symptoms and limitations to both your doctors and the insurance company.
Remember, your claims examiner is going to review some or all of your medical records. If you tell the insurance company that you never leave your bedroom, but your medical records report that you belong to a weekly bowling league, the claims examiner will assume your claim is fraudulent. Unless your symptoms and limitations are constant and continuous, it is best to avoid words like “never” or “always” when describing your symptoms.
Similarly, limit your social media usage while your LTD application is pending. Many people tend to glamorize or overstate their lifestyle on social media feeds like Facebook, Instagram, and Twitter. Likewise, most people don’t write about their bad days or limitations on social media. During the pendency of an LTD claim, the insurance company may monitor your social media accounts, looking for evidence that you are capable of working.
Do Not Overstate Your Abilities
Sometimes, disability claimants overstate their abilities. It can be difficult to admit that you are unable to do certain things. However, if you gloss over or minimize your functional limitations, the insurance company will assume that you can work.
If your doctors or the insurance company ask you about your daily activities or hobbies, be honest. For example, do not list basketball as a hobby if you haven’t played in years. Be specific too—watching a game from your comfortable recliner is different than sitting in the bleachers. Lastly, remember to mention rest periods if they are part of your routine.
Don’t Ignore the Paperwork and Other Claims Requirements
During the application process, your claims examiner may send you forms to complete. He or she may also schedule you for an independent medical examination (IME). It is important that you comply with the insurance company’s requests. If you refuse to complete a form or attend an IME, the insurance company may assume that you are hiding something. Your non-cooperation may result in a denial of benefits. If you need help with a form, ask your ERISA lawyer or a loved one for assistance. Only ask to reschedule an IME for legitimate reasons – for example, if you have a conflicting and important doctor’s appointment.
Don’t Harass Your Claims Examiner
While it is important that you follow up with your claims examiner, excessive phone calls or communication may be considered a “red flag.” If you constantly call your claims examiner or send frequent and detailed letters, the insurance company may think that you are able to work.
Don’t Self-Diagnose Your Medical Conditions
When completing an LTD application, never list a medical condition that a doctor has not diagnosed. A claims examiner will never approve an LTD claim that is based solely on self-diagnosed conditions. You must have medical evidence supporting your claims for benefits.
Don’t Skip Medical Appointments
Claims examiners rely heavily on medical records. When you have a doctor’s appointment, your medical provider documents your symptoms, limitations, and their clinical findings. If you avoid doctor’s appointments or minimize your symptoms and limitations, the claims examiner may believe that your symptoms are mild. For this reason, you should seek medical treatment, when necessary. Make sure to provide good explanations of your symptoms and history when you see a doctor. Giving your doctors accurate information will help your doctor accurately diagnose and treat your conditions, and will serve as evidence in your disability insurance claim.
“Unavoidable” Red Flags
Unfortunately, some red flags are unavoidable, and some things are completely out of your control. In these cases, you must have a well-developed claim for benefits (and, be prepared to file an appeal). Often, your best option is to enlist an experienced ERISA disability lawyer for help with your application.
Subjective or Self-Reported Medical Conditions
Doctors diagnose many medical conditions through fact-based testing, like blood work or an MRI. However, physicians diagnose some conditions – such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome – almost entirely by a patient’s symptoms. These subjective or self-reported conditions almost always raise a red flag. If a doctor diagnoses you with a subjective medical condition, it is important that you have strong medical evidence. When possible, treat consistently with doctors who specialize in your condition. If recommended by your doctors, undergo diagnostic testing.
ERISA lawyers are familiar with the “working wounded” – employees who continue to work even when they physically or mentally cannot or should not. In some workplaces, seniority and accommodations may allow a disabled worker to maintain employment. When there is a layoff or plant closure, however, many of these employees are forced to file for disability benefits. Unfortunately, insurance companies may focus on their recent financial crisis and deny benefits. Again, strong medical evidence will help minimize this red flag. If you had documented accommodations at work, make sure the insurance company gets a copy of your employment file or the restriction slips.
Do I Need an ERISA LTD Attorney?
For many disabled workers, the ERISA LTD application process and the insurance-level appeal are the most important steps in a disability benefits claim. If your claim is not properly developed at the insurance company level, you may not be able to “fix” this later on. (ERISA makes it almost impossible to submit additional evidence to the federal court.) Your claims examiner is looking for red flags in your ERISA LTD application. An experienced ERISA disability lawyer can stack your evidence in support of claim and help you avoid red flags that may lead to a denial of benefits.