Reviewed by Paul E. Walker

Disability Insurance companies have multiple approaches to denying valid claims for long-term disability benefits. Once your claim has been denied, you must have an experienced attorney to prepare an administrative appeal in order to maximize your chances of winning in court.

Common Reasons Insurers Provide for Denying a Claim

You want to make it as difficult as possible for the company to deny your claim for reasons including:

  • Failing to provide recent medical reports
  • Lacking evidence demonstrating that you are totally disabled
  • Failing to provide data to support your claim that you cannot do even sedentary work
  • Lacking documentation to support your claims of severe pain which you say is so debilitating that you cannot work at all

Your Policy Is a Contract

Please be aware that you are filing for benefits under a contract, and this is a legal document with language that has real meaning. If you do not understand exactly what the language means, from a legal point of view, then you have very little chance to succeed in a battle against insurance companies with a battery of experienced attorneys who are basically looking for ways to deny your valid claim for benefits.

Why Your Medical Records Decide the Case

When you submit your appeal, it is mandatory that you have the proper documentation and that your documentation has language that clearly supports your claim. For example, if you have severe and unrelenting back pain that radiates down your legs, you no doubt are unable to do any type of work. But if you do not clearly state your complaints to all of the physicians you see, and some of those doctors write notes that make it appear that you are not in pain, the insurance companies will seize on those notes to maintain that your documentation does not support your claim.

For example, if you have the back pain described above but when you go to see your eye doctor for an examination, and you do not mention this to him, he may write something like, “Patient is in his usual state of good health and is here for a routine eye exam”. The insurance company will pounce on notes such as this and take the position that your claim of back pain is a lie.

Tell Every Doctor the Full Story

Many people do not want to admit that they are disabled. Accordingly, they play down their disability when seeing a doctor. Please do not do this. If you are in excruciating pain, tell the doctor exactly that — in no uncertain terms. And do so consistently, every time you go to the doctor. If you fail to honestly tell each doctor about the extent of your difficulties, the company will use that failure against you.

An example is if your doctor writes down, “Full range of motion both legs with 5 out of 5 strength and no loss of sensation.” Your company will point to that language to claim that whatever problem you might have had, you have completely recovered and therefore your claim is denied. So, when you go to your doctor, please make certain that you clearly articulate your physical situation to the doctor so that he accurately writes notes that reflect your true condition on each and every visit.

How These Denials Are Built

Denials are typically dependent on two opinions arranged by the company. First, a physician will review your records, without examining you, and conclude either that the evidence is subjective or that you can handle less demanding work. Next, an employment specialist will identify jobs that exist in your area and pay enough to put you outside of the policy’s definition of “disabled.” The denial letter will combine these and stop your payments.

Beware the Transferable Skills Analysis

Prior to a denial, most insurers require a Functional Capacity Examination, which often includes a Transferable Skills Analysis. The FCE will determine if you can perform your own occupation, while the TSA determines if you may be able to perform some other less demanding job that pays just enough to end your benefits.

What to Keep in Mind During the Exam

  • The examiner is paid by the insurance company, and everything you say, do, or write becomes part of the analysis.
  • Make sure the examiner has complete and accurate information about your condition before testing begins.
  • Fill out the questionnaire carefully. Every question has a purpose, and none of it is idle background.
  • If a movement hurts, say so at the time. This is not the moment to push through pain to show how tough you are.
  • Be candid about lifting, carrying, walking distances, and sitting and standing, including what you can do and what you cannot.
  • Assume you may be observed or filmed arriving, leaving, and in the days around the exam, since the company knows exactly when and where it is.

Why the Appeal Is Your One Real Chance

A denial letter informs you of how long you have to appeal, and for employer-provided policies, this is typically 180 days. You should not treat the appeal as a formality. If you later proceed to federal court, the judge will typically only review documents already in the insurance company’s file. You cannot add medical records, expert testimony, or test results later. Anything not included in the appeal is considered permanently excluded.

The appeal is where the work begins, as you will need to compile:

  • Comprehensive medical records
  • Clear statements from treating physicians
  • Your own occupational expert, if necessary

In one matter our firm handled, we retained an occupational specialist for a nurse whose benefits had been cut off, and the analysis of the specialist determined that, given her age and cardiac condition, she could not perform the work as her insurer claimed she could. Ultimately, her benefits were restored through the appeal. Prior results do not guarantee a similar outcome.

Because deadlines and procedures differ depending on whether your policy was provided through an employer or purchased individually, you’ll need to confirm early to determine which rules apply to your policy.

There are many more aspects to this disability insurance area of law, so please read our other articles, which will give you additional information to help you. Remember, you will do best with the assistance of an experienced attorney who can prepare an administrative appeal that will give you the best opportunity to succeed.

Contact an Experienced New York City Disability Claim Firm

At Walker Medical Law, our firm understands how complicated these matters can be, which is why we will do everything in our power to help you fight for the best possible outcome for your circumstances. When you need help, do not hesitate to contact our firm today.