An ERISA disability claim denial can be devastating. If your long-term disability (LTD) or short-term disability (STD) claim was denied, you are not alone. Insurance companies deny thousands of disability claims every year. However, many of these denials can be challenged with the right evidence and legal strategy. As a result, understanding why insurers deny ERISA disability claims is the first step toward fighting back and recovering the benefits you deserve.
This guide examines the most common reasons insurance companies use to deny disability benefits and provides strategies for overcoming each type of ERISA disability claim denial.
Insufficient Medical Evidence
One of the most frequently cited reasons for an ERISA disability claim denial is that the claimant failed to provide sufficient medical evidence. Insurers may argue that:
- Your medical records do not document objective findings consistent with disability
- Your treating physicians’ opinions are not supported by clinical evidence
- You have not undergone sufficient diagnostic testing
How to fight back: First, obtain detailed narrative reports from your treating physicians explaining your diagnosis, clinical findings, functional limitations, and why you cannot work. Additionally, consider obtaining a functional capacity evaluation (FCE) that objectively measures your physical or mental capabilities. Finally, include all relevant diagnostic tests, imaging studies, and laboratory results.
Reliance on Paper Reviews Over Treating Physicians
Insurance companies frequently hire non-examining physicians to conduct “paper reviews” of your medical records. These reviewers never examine you but nonetheless render opinions that your condition is not disabling. As a result, courts have criticized this practice. This is especially true when the paper reviewer contradicts the opinions of treating physicians who have actually examined the claimant.
How to fight back: Document the credentials and treatment history of your treating physicians. Then, obtain detailed statements addressing the specific reasons the insurer cited for denial. In addition, point out in your appeal that the reviewing physician never examined you and may have “cherry-picked” evidence from your records while ignoring findings that support your claim. Furthermore, research the reviewing clinician’s credentials and their qualification to evaluate your disability.
Surveillance and Social Media Evidence
Insurers frequently use surveillance investigators to observe claimants and scour social media for evidence that contradicts disability claims. For example, a photograph of you at a family gathering or a video of you carrying groceries may be used to argue that you are not as limited as you claim.
How to fight back: Remember that brief activities captured on video rarely reflect your overall functional capacity. In fact, courts have recognized that performing isolated activities does not necessarily mean you can sustain full-time employment. Therefore, provide context for any surveillance evidence and obtain physician statements explaining how your condition affects your ability to work on a sustained basis.
ERISA Disability Claim Denial at the “Own Occupation” to “Any Occupation” Transition
Many LTD policies pay benefits for 24 months if you cannot perform your own occupation. After that, they require you to prove you cannot perform any occupation for which you are qualified. This transition point is a common time for insurers to terminate benefits.
How to fight back: Obtain a vocational analysis from a qualified expert addressing what jobs, if any, you could perform given your age, education, work experience, and functional limitations. In addition, address not only your physical or mental capabilities but also whether you could sustain full-time employment and earn a comparable income.
Mental Health and Self-Reported Symptom Limitations
Many disability insurance policies limit benefits for conditions based on self-reported symptoms or mental illness to 24 months. Insurers frequently argue that conditions like chronic fatigue syndrome, fibromyalgia, or chronic pain fall under these limitations.
How to fight back: Obtain documentation showing that your condition has an organic basis and is not solely dependent on subjective symptom reports. Importantly, courts have held that insurers cannot impose objective evidence requirements for conditions that cannot be objectively measured, such as fibromyalgia.
Pre-Existing Condition Exclusions
Some disability policies exclude coverage for conditions that existed before you enrolled in the plan. As a result, insurers may deny claims by arguing that your current disability is related to a pre-existing condition.
How to fight back: Review the policy’s specific definition of “pre-existing condition” and the applicable look-back period. Then, obtain medical evidence distinguishing your current condition from any prior health issues. In many cases, the connection between a pre-existing condition and current disability is tenuous at best.
Failure to Follow Treatment
Insurers may deny benefits if they determine that you have failed to follow prescribed treatment. Similarly, they may argue that your condition could improve with additional care.
How to fight back: Document your compliance with all recommended treatments. Also, explain any reasons why certain treatments were not pursued, such as side effects, cost, or physician recommendations against treatment.
Cherry-Picking and Selective Review
Courts have repeatedly criticized insurers for “cherry-picking” evidence that supports denial while ignoring evidence favorable to claimants. This selective review violates the insurer’s fiduciary duty to conduct a full and fair review of your claim.
How to fight back: In your appeal, specifically identify evidence in your claim file that the insurer failed to address. Additionally, point out inconsistencies between the denial rationale and the actual contents of your medical records.
Contact The Garner Firm for Help With Your ERISA Disability Claim Denial
If you are dealing with an ERISA disability claim denial, you need an experienced attorney on your side. At The Garner Firm, our ERISA disability attorneys have helped hundreds of clients overturn wrongful denials and recover the long-term disability benefits they deserve. We understand the complex rules governing ERISA claims, appeals, and litigation. Contact us today at (267) 805-6557 for a free consultation about your case.