Why Disability Insurance or ERISA Claims Are Denied

Insurance companies and claim administrators routinely use standard excuses for denying disability claims. These excuses usually fall into one of the following categories:

Excuse #1: Medical Records Do Not Support Your Disability

The excuse that your medical records do not support your inability to work in your job may be given because the insurance company or Plan has misinterpreted your medical records, or because your medical records don’t adequately document your limitations because of your medical condition. Physicians are trained to diagnose and treat medical conditions. They are not necessarily the best at documenting physical or mental limitations associated with a physical injury or illness. In these situations, Stennett Casino will need to assist the doctor to document your condition or refer client to other professionals who can objectively document their disability.

Excuse #2: There is no Objective Evidence Supporting your Disability

Most policies do not require “objective medical evidence” to substantiate a disability. Nevertheless, administrators constantly deny cases based on a lack of objective medical evidence. Often, there is objective medical evidence, but the insurance company doesn’t view it as such. At other times, we need to have further testing and evaluation performed so that your limitations are objectively verified. If these efforts fail, then we point out the legal insufficiency of the Plan or company’s position that there is “no objective medical evidence” when the Plan contains no such requirement.

Excuse #3: Your Physical Limitations Do Not Preclude You From Performing the Duties of Your Own Occupation

The insurer may acknowledge that you have a physical injury or illness which restricts your abilities. However, their vocational expert will report that even with your limitations, you can perform the duties of your occupation. This situation requires a thorough analysis of the duties of your occupation versus your limitations. It often requires the hiring of a vocational expert who can analyze the requirements of your job and your ability to perform your occupation.

Excuse #4: Claim Denied Based on an Erroneous Definition of “Your Occupation”

Most professional disability policies defined “disability” as an inability to perform one’s “own occupation.” For example, a physician’s occupation may be defined as his/her specific specialty, such as that of a surgeon. In denying these disability claims, the insurance company will apply a broader view of the occupation and take the position that the insured’s own occupation is not that of a surgeon, but that of a physician. Thus, even though he cannot perform surgery because of limitations such as hand tremors, he can continue a practice as a physician. Courts have examined this issue and have concluded that the occupation of a surgeon cannot be defined as a physician in that a surgical practice even though it includes seeing patients in the office cannot be sustained with the physician cannot perform surgery. Similar issues arise in other occupations such as attorney versus trial lawyer, artist versus business owner, and inside sales versus outside sales. A closer look at the duties of the client’s specific occupation and the help of a vocational specialist are often critical in these cases.

Excuse #5: You Are Not Disabled From Performing Any Occupation

A second definition of disability often found in disability policies is an inability to perform the duties of “any occupation.” Many policies define disability as an inability to perform your “own occupation” and then change to “any occupation” after 24 months. When there is a change in the definition of disability after 24 months this is often when a person’s benefits are terminated. This situation requires the review of your work history, training, and education to determine whether you are able to perform the duties of the occupations the insurer claims you are able to perform.

Excuse #6: Your Disability is Caused By a Mental Condition

Mental/emotional conditions are typically not covered or have only limited coverage under long term disability policies. Coverage is usually limited to 24 months. Depression and anxiety is associated with virtually every long term disability claim. The inability work and the pain associated with a physical injury often causes depression and anxiety. Administrators and insurers use this to their advantage by claiming that your diagnosis of depression/anxiety is the cause of your disability, not just a symptom of your underlying illness or injury. There are numerous effective arguments that can be made to overcome this defense, depending upon the specific facts of your case and the terms of your policy.

How We Can Help

The denial of a disability claim is devastating. People who are totally disabled can’t earn money to support their family or themselves, and desperately need their disability benefits. Despite this, insurers and plan administrators routinely deny valid claims. They do not limit their denials to hard-to-prove illnesses like fibromyalgia, chronic fatigue, myofascial pain syndrome, back pain and depression. Even clients with terminal illnesses such as cancer have needed Stennett Casino’s help to obtain benefits.

When you retain the Law Firm of Stennett Casino, we expertly evaluate your claim. We determine the documentation and evidence needed to help avoid or rebut common grounds for claim denial: insufficient proof of your job requirements, your medical condition, or how your medical condition prevents your job performance. We work with your doctors, employer, co-workers, and any outside specialists (such as medical or rehabilitation experts) to obtain the necessary evidence and documentation. We conduct investigations and interviews where useful, obtain any studies and reports that support your claim, and review, organize and summarize every item in your file for the Plan Administrator or Insurance Company. We also present the legal arguments needed if the Plan conflicts with California or Federal law.

A simple phone call to Stennett Casino often can start you on the correct path toward obtaining your benefits. Your initial consultation is free. Although the result in each case depends on its unique facts and law, we’ve had many successes in obtaining disability benefits for our clients.

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