People ask me all the time, “Why do most claims get denied?” There are very simple reasons, very common reasons why many claims are denied by insurance companies. The most cynical explanation is that most insurance companies don’t expect people to file a proper appeal. So they’ll just stamp denied on the claim and just hope for the best. Most of the people probably aren’t going to appeal it. If they do appeal it, an even smaller percentage of those people will hire attorneys for help as they go about the appeal process.
Why Do They Just “Stamp Denied” on Claims?
Now, remember, we’re talking about ERISA long-term disability claims that are policies or benefits that are provided by an employer for an employee, and that are governed by the Employee Retirement Income Security Act. That’s what we’re talking about. A lot of times, they’ll just stamp denied on that claim form and send it back and hope for the best. But oftentimes, they can do that because the person who is filing the claim hasn’t given them all of the information that will substantiate the disability. You have to be able to identify what the disabling condition is, what the symptoms of the disabling conditions are, and then how did those symptoms prevent you from doing the main functions or the main duties of your job.
What You Need to Know
Now, every insurance policy has a different definition of what a disability is, but almost all of them track along those same lines. So you have to be able to identify, “What were the main duties of my occupation?” and, “Why can I not do them because of this disabling condition?” You have to provide medical support for why you can’t do those things.
A lot of times what people do is they’ll get a listing of all the medical records and they’ll just plop the medical records down in front of the claims specialist, who is supposed to review that and figure out what your diagnosis is and then how that diagnosis affects your ability to do your job. But none of that is documented in your medical records. You have to provide additional information that is helpful to the claims specialist to make sure that they can see how this diagnosis over here affects my job over here. Those are two separate things.
You Are Responsible for Providing Medical Documentation
The insurance company is not going to make that logical leap on its own. You have to help the insurance company to make that logical leap. The only way to do that is to provide additional documentary evidence that will establish what that link is, and then you have to bolster that evidence. Perhaps an affidavit from you describing the type of condition that you have, describing the symptoms that you have and describing how those symptoms affect your ability to work. Then you have to take that and put down your doctor’s information and get your doctor to write a narrative report, or your attending physician’s statement. Doing this will substantiate your claims that these symptoms prohibit you from performing the main duties of your occupation.
What is Considered “Main Duties” of Occupation?
You may wonder, “What are the main duties of my occupation?” These are duties that are essential to your job, and they’re duties often that cannot be cured by some type of an accommodation. For example, if you have difficulty concentrating with loud noises going around, could you do your job in an office? So if your employer were to put you in an office, does that solve your disability? If it does, then you’re probably not going to fit under the definition of disabled in your insurance contract. If it doesn’t, then you have other issues and you probably have a stronger argument that you cannot perform the main duties of your occupation, even with a reasonable accommodation.
There are several reasons why most claims are stamped denied. Of course, my cynical perspective wants to say, “It’s been denied because they’re just not optimistic that you’re going to appeal. And that if you are going to appeal, they’re still not optimistic that you will provide everything that you need to provide in order to win your appeal, and then defend that position in court.” So all of your documents, everything that you intend to offer as proof in court has to be offered to the insurance company when you file your claim or when you file your appeal. You can’t just send them an email that says, “I appeal,” because that’s not good enough. You have to provide additional information that will support your claim and that will rebut their reasons for denying your claim.
It’s a very long and complicated process. If you need help, we’re happy to help you with that. Give us a call or send us an email. We’ll sit down either face to face or over the internet or over the telephone, and help walk you through some of the nuts and bolts of these issues.
