ERISA • Employment Law

Reasons Your New Jersey Long Term Disability Claim Might be Denied

05 Nov 2019

Many long-term disability, or LTD, policies are regulated under ERISA. This is a federal law that stands for the Employee Retirement Income Security Act. When you make a claim for benefits, it is typically evaluated by a claims adjuster who works for the insurance company. Unfortunately, it is not uncommon to have claims adjusters deny valid long-term disability claims, even when there is evidence of a claim’s validity. While it’s certainly not fair, the fact remains that claims administrators routinely deny claims. 

It is important to understand some of the potential reasons for denial, some of which are legitimately valid. Also, it is important to contact a knowledgeable long-term disability lawyer admitted to practice law in New Jersey. The Garner Firm has extensive experience representing clients who have been unfairly denied for long-term disability benefits under an ERISA-regulated benefits plan. 

You Do Not Meet the Policy’s Definition of Disabled

This is one of the most common reasons for denial of LTD benefits. The definition of disabled is exact, and if you do not meet it, you will be denied. To make it even more confusing, the terms change over time. For example, it transitions from unable to perform the duties of “your regular occupation” to “any occupation” after the first 24 months.

Surveillance and Online Evidence

 You can expect that the claims administrator will be looking at your online activity and social media accounts. They may even hire an investigator to surveil you in person. They are looking for proof of your daily activities and video evidence of you doing something that proves (in the mind of the claims administrator) that you are not disabled. Expect them to show things out of context, as well. Perhaps your claim is for fibromyalgia. Most patients report having some good days. If you are outside and lifting a light object or doing some maintenance work around your yard, that may be enough for them to contend that you are not disabled.

Pre-Existing Conditions and Exclusions

If you have a pre-existing condition, it can limit your benefits. Some policies may consider a pre-existing condition to exist if you sought treatment or took prescription medication for a condition and went to the doctor in the months before your insurance took effect. Your insurance company could then deny benefits for a 12-month period after your insurance became effective. Once the 12-month waiting period is over, you would be covered for LTD, in theory.

In some cases, conditions themselves are excluded. These can include impairments related to substance abuse or alcohol. Conditions that include subjective complaints rather than objective ones (like chronic fatigue syndrome) may be limited in duration, typically the first two years.

Missed Deadlines 

There are strict deadlines when it comes to long-term disability benefits. If you miss one, it could result in a denial. In most ERISA-governed plans, you only have 180 days to appeal an initial LTD denial.

Contact a New Jersey Long-Term Disability Insurance Attorney Today 

Making sure you meet deadlines and present all valid evidence during the claims process is key. Let a New Jersey LTD insurance attorney help. Contact The Garner Firm today to schedule an initial consultation today.

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Mr. Garner is an ERISA employee benefits and employment attorney with over a decade of experience. The laws governing employee benefits, the employment relationship, and the workplace are complex.

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