Reasons for Denials of ERISA Disability Claims

Many people make career decisions with employee benefits in mind. Being covered by employer-sponsored health, life, and disability insurance can provide peace of mind that you and your family have a safety net should the worst happen. This is especially the case with disability insurance.  Disability insurance protects you if you cannot perform the important duties of your occupation because of an injury or sickness and thus cannot work at your job.  What do you do if you cannot work due to medical conditions that prevent you from performing your job duties and your ERISA disability insurer denies your disability claim?

ERISA-related disability claims are often denied for numerous reasons. Here are some of the most important and common reasons for denial:

1. Insufficient Medical Evidence

• Explanation: The claimant fails to provide adequate documentation or medical evidence to support the claim of a disabling condition.
• Details:
  • Lack of detailed physician reports or diagnostic test results.
  • Gaps in medical treatment or inconsistent medical records.
  • Opinions from medical professionals that do not align with the claimed disability.

2. Definition of Disability Not Met

• Explanation: The claimant does not meet the policy’s definition of disability, which can vary between plans.
• Details:
  • Some plans distinguish between “own occupation” and “any occupation” definitions of disability.
  • Claims are often denied if the insurer determines that the claimant can perform some form of work, even if it is not their previous occupation.

3. Pre-existing Conditions

• Explanation: The disability is linked to a pre-existing condition that is excluded under the terms of the policy.
• Details:
  • Policies often exclude coverage for conditions that existed or were treated during a specified period before coverage began.

4. Failure to Follow Treatment Plans

• Explanation: The claimant does not follow prescribed treatment plans or fails to attend required medical evaluations.
• Details:
  • Insurers may argue that treatment adherence could improve the condition and enable the claimant to work.

5. Lack of Objective Evidence

• Explanation: Many policies require objective medical evidence (e.g., imaging or lab results) to substantiate the claim.
• Details:
  • Claims based solely on subjective symptoms like pain or fatigue may be denied if they lack corroborating objective evidence.

6. Administrative or Procedural Issues

• Explanation: Errors or omissions during the claims process can lead to denial.
• Details:
  • Missing deadlines for filing claims or appeals.
  • Failing to provide requested documents or forms.
  • Incomplete or inconsistent application details.

7. Surveillance and Social Media Evidence

• Explanation: Insurers use surveillance or social media activity to dispute the severity of the claimant’s disability.
• Details:
  • If the claimant is observed engaging in activities inconsistent with their claimed limitations, the insurer may deny the claim.

8. Independent Medical Evaluations (IMEs)

• Explanation: Insurers often require claimants to undergo evaluations by their chosen physicians, who may dispute the claimant’s disability.
• Details:
  • IME reports that contradict the claimant’s physician’s findings can be used as grounds for denial.

9. Policy Exclusions and Limitations

• Explanation: The disability falls under specific exclusions or limitations in the policy.
• Details:
  • Policies may limit coverage for mental health conditions, substance abuse, or conditions related to self-inflicted injuries are usually limited to 24 months.
  • Some policies cap benefits for certain disabilities to a specific duration.

10. Claims of Improvement or Recovery

• Explanation: The insurer argues that the claimant’s condition has improved sufficiently to allow a return to work.
• Details:
  • Often based on periodic reviews of medical records or IMEs.
  • The insurer may use minimal improvement to justify denial or termination of benefits.

11. Vocational Assessments

• Explanation: Insurers may argue that claimants are capable of alternative work based on vocational assessments.
• Details:
  • Denial may occur if the insurer identifies jobs the claimant is allegedly qualified for and capable of performing.

12. ERISA-Specific Procedural Safeguards

• Explanation: ERISA governs procedural requirements for claims and appeals.
• Details:
  • Denials may result from claimants not adhering to the administrative processes outlined in ERISA, such as failing to appeal within specified timeframes.

Determine Why Your Claim Was Denied

You must start by understanding why your claim was denied. When waiting for insurance payments to help cover expenses, a denial letter can make you angry, sad, and stressed. Take your time and read the disability denial letter carefully and consider why your disability claim was denied.

If the denial letter does not include a reason or you do not fully understand the reason, consider calling or writing to your disability insurer representative listed in the denial letter. In a professional, straightforward manner, ask for more details about the denial. Do not agree to or sign anything, but document any additional information you learn.

Review Your Rights and Benefits

Once you have detailed information about the insurance company’s reasons for denying your claim, turn to your benefits documents. Start by reviewing your disability insurance policy/plan. Understanding your policy can help you support a better chance at a satisfactory appeals outcome. Pay attention to your rights under your plan, such as how long you have to file an appeal and what resources are available if your claim is denied.

Meet With an Experienced ERISA Disability Attorney

Once you have basic information about your case, consider contacting an experienced ERISA disability attorney. A lawyer with insurance claims and appeals knowledge can provide critical information and guidance through the process. That starts with understanding the regulations that govern  ERISA disability insurance claims and making informed decisions about your claim and appeal.

Even if you are unsure as to what you should do or how to handle your next steps, highly experienced attorneys such as McKennon Law Group PC who regularly handle ERISA disability claims can be extremely helpful. They can review your case and tell you whether an appeal is possible and probable.  They can also show you how to achieve the best chances for a positive outcome. Understanding the reasons for denial is crucial for claimants, as it allows them to proactively address potential issues and strengthen their claims or appeals under ERISA-governed disability policies.  Here are several reasons to contact experienced ERISA disability attorneys (like McKennon Law Group PC) when your disability claim is denied:

1. Expertise in ERISA Regulations

• Reason: ERISA is a highly technical federal law with strict rules and procedures. Understanding its requirements can be challenging for non-experts.
• Benefit: An experienced attorney knows how ERISA governs disability claims, appeals, and litigation. They can guide you through the process to ensure compliance and avoid procedural missteps.

2. Assistance with Administrative Exhaustion

• Reason: Under ERISA, you must exhaust all administrative remedies (appeals within the insurer) before filing a lawsuit.
• Benefit: An attorney can help you build a strong administrative appeal, including gathering the necessary evidence and addressing the insurer’s reasons for denial.

3. Navigating Strict Deadlines

• Reason: ERISA has rigid timelines for filing claims, appeals, and lawsuits. Missing a deadline can forfeit your right to benefits.
• Benefit: An attorney ensures that all documents and appeals are submitted on time, preserving your legal rights.

4. Building a Comprehensive and Winning Appeal of a Denied   Disability Claim

• Reason: Insurers often deny claims due to insufficient evidence or technical deficiencies in the application.
• Benefit: An attorney can help you gather and present the medical, vocational, and other supporting evidence needed to substantiate your disability claim.

5. Challenging Denials Effectively

• Reason: Insurers use various strategies to deny claims, such as disputing medical evidence or relying on biased IMEs.
• Benefit: An experienced attorney can identify flaws in the insurer’s reasoning, challenge biased IMEs, and present counterarguments that strengthen your case.

6. Addressing ERISA’s Procedural Barriers

• Reason: ERISA limits the scope of evidence and judicial review in disability cases, favoring insurers.
• Benefit: An attorney understands how to navigate these procedural barriers, ensuring your case is presented in the strongest possible way.

7. Managing Insurance Company Tactics

• Reason: Insurers may use surveillance, vocational assessments, or legal technicalities to undermine your claim.
• Benefit: An attorney knows how to counter these tactics, ensuring that your rights are protected and your case is not unfairly dismissed.

8. Maximizing Success in the Appeal Process

• Reason: The appeal process under ERISA is often your best chance to secure benefits without going to court.
• Benefit: An attorney can help craft a compelling appeal that addresses the insurer’s reasons for denial, includes additional evidence, and maximizes your chances of success.

9. Preparing for Litigation

• Reason: If the administrative appeal fails, ERISA allows claimants to file a lawsuit in federal court.  However, only the evidence presented in the appeal is typically allowed before the judge who will decide your case. 
• Benefit: An attorney experienced in ERISA litigation can effectively represent you in court, leveraging knowledge of case law and legal strategy to challenge the denial, while making sure that all relevant evidence is presented in the appeal process.  

10. Minimizing Stress

• Reason: Handling a disability claim or appeal can be overwhelming, especially while dealing with a disabling condition.
• Benefit: An attorney manages the legal and administrative aspects of your claim, allowing you to focus on your health and well-being.

Gather Evidence About Your Case

Whether you work with an attorney on your case or decide to proceed with the appeals process on your own, the next step is likely gathering evidence. Relevant evidence includes medical records, letters from medical providers, images and videos, and written statements from family, friends, co-workers or employers, certification letters from medical professionals, etc.

The more evidence you can gather to support your claim, the better. You may not need to include everything you gather in your appeal, and a lawyer can help you understand how to create a compelling narrative with supporting evidence for your case.

File an Appeal On Time

It is essential to file any appeal within the timelines set out by your plan and by ERISA’s claims regulations, which are normally set forth in the denial letter from your insurance company. For example, your denial letter may state that you have up to 180 days from the date you receive the letter to file an appeal. An appeal filed after that date may not be effective, as missing the deadline can result in automatic forfeiture of your appeal rights and also your ability to file a lawsuit.

Avoid rushing through the appeals process, which can lead to errors and missing information. However, it may be a good idea to try to file your appeal a few weeks or at least several days before the deadline at the latest. This gives you some breathing room and helps ensure your appeal arrives promptly.

Address the Reason for Denial

In your appeal, make sure you specifically address the reason(s) the insurance company listed for denying your claim. For example, if your insurance company denied the claim because there is insufficient medical evidence to support your claimed restrictions and limitations, then you must focus your evidence and arguments on this rationale for denial.

Consider Including Personal Statements

One thing to consider including in an appeal is personal statements from persons who have knowledge of important facts concerning your claim. For example, suppose you are appealing a disability claim denial. In that case, you should include statements from persons who know your medical conditions and who know why you cannot perform your job duties. Letters from your doctors providing an expert opinion on your disability or statements from family, co-workers or friends about your disability status are often important to include in your appeal.

Prepare to Take the Matter Further if Necessary

Remember that your appeal may only be one step in the overall process of getting your claim paid. Depending on your case, you may be able to seek remedies beyond the appeals process. An experienced ERISA lawyer can help you understand your options.

If you are struggling with an ERISA-related claim denial and need help with your appeal, we can help. Reach out to the McKennon Law Group PC by calling 949-504-5381.