Common reasons that companies deny ERISA disability claims

On Behalf of | May 2, 2020 | ERISA Disability Benefits

Long-term disability benefits claims are among the most expensive for insurance companies to pay. An individual with a permanent disability may require hundreds of thousands of dollars of support over the course of their life between lost wages and medical expenses. As such, the standards that businesses apply when evaluating a condition for a claim for disability benefits can often be prohibitively strict.

In fact, there are circumstances in which individuals who have a reasonable claim to long-term disability benefits wind up denied. Understanding a few of those common causes can help you avoid them when applying for benefits if they might apply to your situation.

The insurance company doesn’t think the condition is severe enough

It is difficult if not impossible to objectively rank the severity of medical conditions because individuals experience these conditions differently. Although some medical ailments may be more severe than others in typical cases, there are always outlier cases that are either unusually mild or exceptionally severe.

For those who have unusually severe versions of typically less disabling conditions, additional medical documentation and reports from multiple professionals who have analyzed how the condition impacts the individual’s ability to function can help drive home the impact of the condition during the appeal process.

The patient hasn’t sought care or complied with medical orders

The longer someone puts off treating a condition, the worse it could potentially become. Once a medical professional recommends a course of treatment, whether it involves surgery or physical therapy, it is incumbent upon the patient to follow those recommendations.

If the insurance company can show that the person filing the claim either hasn’t sought care or hasn’t complied with medical recommendations, that could place the responsibility for the severity of their condition on them while also implying that they could potentially improve their functionality if they were to comply with medical recommendations.

Following doctors’ orders will help you avoid these claims. If you disagree with a course of treatment, requesting a second opinion and getting adequate documentation of that opinion can help.

When a company denies your benefits, your rights under ERISA include the right to a clear explanation for the reason the company rejected your benefits. When you know the reason why, you can better plan on how to address that issue during your appeal.