How To Satisfy Your Insurer’s Interpretation of Total Disability

In addition to adapting to a life with chronic pain which diminishes your work capacity, it often becomes essential to understand how to predict the actions and decisions of your insurance company. There may come a time when you need to convince them that life with your illness is compelling enough to be considered a “total disability.”  Unfortunately, many insurance companies do not understand the daily struggle of illnesses like rheumatoid arthritis. This can be problematic because the burden of proving your disability belongs to you; and pain can be a difficult thing to prove.  At Kantor & Kantor, we have extensive experience representing clients with chronic illnesses.  Our hope is that by sharing some of our knowledge, we can equip and empower you to effectively advocate for benefits to which you are entitled.

In order to receive long term disability benefits, you must not only satisfy your doctor’s definition of disability, but your insurer’s definition as well. In a previous blog post, we talked about how insurance companies define disability. It is important to understand this because most disability insurance policies will use two disability standards, based on the length of your disability. These standards include:

  • “Own occupation” – You will be required to prove that your illness or injury prevents you from performing the material duties of your own occupation, not necessarily the job as you were performing it for your employer. Many policies limit this definition to the first 12 or 24 months of disability benefits.
  • “Any occupation” – After the specified “own occupation” period, you will have to show that your illness or injury prevents you from performing any occupation, usually considering your education, training, and experience.  Sometimes the policy will limit the any occupation definition to “gainful” occupations.  Meaning the ability to perform an occupation where you would earn a wage at a specified level, or commensurate with your station in life.

The claims process works like this: once you make a long term disability claim with your insurance company, your insurer will need to verify that you are in-fact covered under a policy. This requires verification that you have the insurance coverage that you are seeking. If you are covered, the next step is to evaluate the merits of your claim. The insurance company will do so based on the definition of disability found in the policy. Be mindful of the techniques listed below that some insurance companies utilize to deny disability claims. In our experience, many adverse disability determinations are based upon the following reasons:

“No Objective Findings”: Insurers will often demand “objective” evidence of your disability…even if such evidence is difficult or impossible to obtain.  You must do your best to provide them with as much evidence as you possibly can. Because illnesses like RA are more or less “invisible” and difficult to objectively prove, you should not rely on your insurance company to draw the correct conclusions about your disability. Treatment notes from your physician can be considered clinical documentation that should satisfy any need for objective verification. Thus, it is critical that your treatment providers accurately record your symptom severity against a clear baseline.  In addition to medical records, supplement your claim with narrative statements from your treating physicians. Get written support from your employer and people in your personal life that can explain how debilitating your illness has been.

“Disability is related to specific job as opposed to own occupation”: Prepare for the insurance company to draw inaccurate conclusions about your job duties. When evaluating your ability to perform your occupation, the claims administrator will often look at how your job is performed in the national economy rather than looking at the specific requirements of your job. Thus, the insurer might deny your claim on grounds that although your specific job might have strenuous or stressful components, the occupation itself does not have such requirements. Therefore, according to this logic, you are not disabled. Be wary of claims administrators who utilize generalized or inaccurate job descriptions that do not correspond with your job responsibilities! Your employer/former employer can certainly provide an accurate description of your occupation, but do not rely entirely upon them either. Take the time to verify that the job description they provide to the insurance company accurately reflects your job duties. If it does not, bring this to the attention of your insurer and employer.

This also provides you with an opportunity to highlight the changes in how you might have performed your occupation over time to deal with the onset of RA and why it is now causing your inability to work.  This is why it is important to get written support from your employer, and ask for a copy of your personnel file. This information may show your history of good performance reviews followed by your struggles to perform at a satisfactory level, corresponding to the time of the onset of your illness.

Even if you present the insurance company with medical records overflowing with evidence of your illness, and letters of support that document and objectify your illness, it is still possible to receive a long term disability denial from your insurer. It is important to understand that an insurance denial is not the final word. Under the Employee Retirement Income Security Act (ERISA), you have a legal right to appeal the denial of disability benefits. Unfortunately, the burden and responsibility of proving your claim is still yours, so take the appeal opportunity to cure any defects in your claim.  If the denial is upheld, you then have the right to file a lawsuit to enforce your rights.

Communicating with insurance companies can be a tedious and exhausting venture. The stress from dealing with a Long Term Disability denial only adds to the difficulty of living with chronic illness. If you have questions about your LTD insurance denial, Kantor & Kantor can help. We offer no cost consultations, and we work on a contingency basis–meaning we do not collect a fee unless we get your claim paid. See our website for more information or call us at (800) 446-7529.

We understand, and we can help.

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