Top 8 Reasons LTD Claims Are Denied

Top 8 Reasons LTD Claims Are Denied

  1. Incomplete or late LTD Applications: Your claim may be denied if your forms are not completed properly or sent in within the insurance company deadlines.

  2. Pre-Existing Medical Conditions: If you have only had your group benefits for a brief period of time and had a medical condition in the past, the claim will be reviewed to determine whether the claim can be denied based on the pre-existing exclusion clause in your group policy.

  3. Negligent or Fraudulent Misrepresentation: If you have a private or individual LTD policy, the rules regarding pre-existing medical conditions are different. If your claim for disability arises within the first two years after you have had your policy, the insurance company will likely review the answers you gave when you took out your insurance to see if you failed to disclose any relevant medical conditions to see if they can deny your claim and cancel your policy based on misrepresentation. After the first two years, they may also check for misrepresentations to see if they can make out a case for fraudulent misrepresentation.

  4. You Are Ineligible for Coverage: This may arise if you haven’t worked long enough for your company, or don’t work enough hours per week to qualify for coverage.

  5. Other Policy Exclusions: In addition to the pre-existing exclusion, LTD policies include other exclusions. As an example, if substance abuse forms the basis of a claim, failure to participate in an appropriate treatment program for the substance abuse could be cited as a reason for a claim to be denied.

  6. Objective Evidence or Insufficient Information: Perhaps the most frequent reason for a claim denial is that the insurance company is not satisfied with the medical information that has been provided.   An area that is extremely frustrating for you and your health care providers, who are supporting your claim.

  7. Receiving Appropriate Care and Treatment: You must be under the regular care of physicians and health care providers that are appropriate for the medical condition you are suffering with.

  8. Private Investigation: Your activity level may be subject to surveillance by a private investigator and your online activity may also be monitored to see if your level of activity is consistent with the disability being claimed.

  9. Change of Definition:  Many insurance companies will terminate benefits at the change of definition (see below) if they believe that you can work at some other occupation.

(Change of Definition: For the first 24 months (or the applicable period), you are totally disabled from the essential duties of your own occupation. After 24 months (or the applicable period), you are totally disabled from the essential duties of any occupation for which you have the requisite education, training or skill to perform.

Has your long-term disability claim been denied? Contact Share Lawyers and put our experience to work for you. We have recently settled cases against Standard Life, Desjardins, Manulife, RBC Insurance, Sun Life, and much more. We offer free consultations and there are no fees unless we win your case. Find out if you have a disability case.