Have you ever wondered why the insurance company is allowed to deny your long-term disability claim because of a doctor that never saw you? You have your treating doctors who provide you with medical care, and they tell you that you were disabled. So, you do what you’re supposed to do and you file your long-term disability claim. Then, the insurance company talks to a doctor and that doctor says you’re not disabled. The only difference is the insurance companies’ doctors never leave eyes on you.
This is the classic battle of the experts seen in so many legal cases involving injuries or disabilities. Usually, the expert who has a better basis for knowledge has the upper hand. However, on occasion, the insurance company will discard your treating doctor’s opinion and rely on the opinion of a doctor who never saw you. Sometimes, the insurance company will even discard four or five treating doctors in favor of the one record reviewing doctor’s opinion. Unfortunately, this happens all the time and long-term disability claims.
What to do after your long-term insurance is denied?
First, if your claim has been denied you have to make sure that you file an appeal with any applicable timeframe set forward in your policy. Your insurance policy will determine when you have to file your appeal.
Second, you have to make sure to produce enough evidence in response to the insurance company’s denial that will convince them that they made the wrong decision. You have to think long term and anticipate future litigation and consider what would a judge do if he or she compared the medical evidence against each other.
Insurance companies are allowed to investigate your claim and to determine if your claim has merit. Part of that investigation usually includes a doctor hired by the insurance company to evaluate your medical records. It is critical to make sure that this doctor reviews every medical record that is relevant. If that doctor does not consider every medical record when you have a basis for disposing of his opinion.
The ultimate goal in every long-term disability appeal?
Your goal in this appeal is to make it look like the insurance company’s denial is based on bad information. In order to do that you have to produce enough information that would make the insurance company look unreasonable if they stick to their decision. The biggest piece of evidence that you can offer would be a complete medical opinion from your training doctors saying that you are completely disabled and why. If your medical doctor is not willing to say that you were completely disabled, then you will likely lose your appeal.
The old adage garbage in garbage out applies as an equal force in this instance. If you did not submit enough information to justify the insurance company granting your disability benefits, then you will be denied. Your only opportunity to present new information after your claim is denied is during the 180 day appeal period. If you fail to submit new medical or vocational information sufficient to change the insurance companies opinion, then you will like likely be denied again.
If you are once again denied, then you’re only recourse is to file a federal lawsuit against the insurance company and federal district court. The federal judge will review the end administrative record the insurance companies entire claim file and decide whether the insurance company abused its discretion in denying your claim. The abuse of discretion standard is a very low standard for the insurance company but a very high standard for you.