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Understanding why your disability claim was denied

Have you had your disability benefits denied? Disability insurance policies are complex and contain numerous provisions designed to limit the amount of benefits you receive. An experienced disability attorney can help you understand the provisions of your policy and help you to get the maximum benefits.

The Two Types of Disability Insurance Regardless of the source of insurance coverage, all disability insurance can be divided into two types, "general" and "occupational." Social Security disability insurance is a primary example of what would be classified as "general" coverage. In order to qualify for benefits the insured must establish an inability to perform the duties of any occupation.

Occupational disability insurance insures against the inability to perform the significant duties of one's own occupation. In some instances, occupational disability insurance is further defined as one that insures against the inability to perform one's particular specialty; i.e., "accountant." One of the complexities dealt with in the denial of occupational disability claims is brought up when one has more than a single occupation; i.e., accounting and teaching. If the insured is able to perform the duties of one of the occupations and not the other, benefits may not be payable.

Your condition may be subject to a 2-5 year Limit for benefits paid due to mental or nervous conditions, and insurance company employees have learned how to steer your claim into this category. If your disability is not physical, you may be labeled mentally ill, often by an on-site physician who has never seen the claimant and whose identity and qualifications are unknown.

If the claimant's list of symptoms includes depression, anxiety or panic attacks, these symptoms will be magnified, while pages of medical evidence supporting the claimant's physical disability may be ignored. If the claimant is being treated by a psychotherapist or uses anti depressants for symptomatic relief, the insurer may insist that the claimant's primary condition is psychological. The highly restrictive criteria developed to screen patients for research purposes are widely misused by insurers.

A patient wrote: "Not only did my insurer insist that my symptoms were due to major depression, but they also demanded that I be under the care and treatment of a psychologist or psychiatrist, and that I provide a letter certifying disability from one of these doctors before they would pay any benefits." A health care worker, still hoping to return to work, was deeply distressed about the insurance company's diagnosis, and agreed to anything her claims representative demanded in exchange for assurance that her employer would never be told she had been classified as mentally ill. Some insurance companies consider some disabilities mental or nervous disorders, therefore limiting your payments to two years.

Accidental disclosure of confidential information is often used to intimidate employees applying for medical and disability benefits. Despite assurances that medical information will not be shared with employers, letters from disability insurers to claimants discussing their alleged physical or psychiatric conditions are sometimes copied to employers, violating claimants' rights to privacy. The American Psychiatric Society has documented many instances of employee medical and psychiatric information being placed in the hands of employers or coworkers with embarrassing and even tragic results. In the book Privacy in America, David Linowes reports that some insurance companies prefer to have claims processed through employers' personnel departments as a way to pressure employees not to use their insurance.[1]

Your disability classification may be denied because the insurer insists that your subjective symptoms do not provide objective evidence of disability. While there is no single method of denial applied to all claimants, and new excuses to deny claims have developed over time, the policy of magnifying minor evidence to limit or deny claims has been consistent. One claimant was denied for not providing evidence of a sore throat, while others who documented this symptom were also denied. Another claimant was told that he must provide objective lab testing to support his diagnosis. When he inquired what tests he needed to prove his claim, he was told that the company knew of none.

Sometimes the reasons for denials are trivial and appear to ignore all medical evidence. One claimant's benefits were terminated immediately after a claims worker arrived at her home without an appointment and reported, "she did not look tired and had no dark circles under her eyes"; another was told she was "just tired and needed a vacation". A woman at the peak of her career was accused of applying for disability because her husband had retired; another professional woman whose symptoms had gradually worsened over the years was denied because the insurer learned her position was going to be eliminated. A fibromyalgia patient lost his benefits after a surveillance team videotaped him working in his garden, an activity suggested by his doctor.

Independent medical examinations (IMEs) are frequently scheduled by insurers to rebut medical evidence provided by claimants' physicians. Examiners selected by the insurers are often biased against or ignorant of mental illness related disability. YOu may be told your examiner knows nothing about your illness or that your condition is not a valid diagnosis for disability. A woman with such severe symptoms that she could stand for only a few minutes was pronounced capable of returning to work after a physical medicine specialist took measurements of her arms and legs.

Many physicians are required to submit their office notes and provide detailed reports at frequent intervals to the insurer. When physicians are unable to keep up with these demands, their patients have been threatened with loss of benefits. Insurers have also deliberately distorted and taken out of context physicians' statements in order to deny benefits to their claimants. Physicians who wrote to insurers protesting that their words had been twisted to mean the opposite of what was intended were simply ignored.

Insurers often insist that patients provide irrefutable objective evidence of their disabilities, yet reports from the insurers' own medical departments are not subjected to the rigorous scrutiny which reports from claimants' physicians must endure. The qualifications, medical experience and specialities of the insurers' anonymous "in-house" physicians are unknown, and the outside physicians paid by insurers to perform independent medical examinations are often grossly unsuited to diagnose patients with these complex, poorly understood conditions. After waiting several months for a decision, your claim may be denied citing "a preponderance of medical evidence," although this preponderance is never produced. Similarly, claimants who asked for ERISA reviews from one insurer received identical, boiler-plate letters asserting that "our decision still stands." Those who asked what was needed to perfect their claims were never given this important information.

In contrast, claimants with individual LTD policies have less difficulty with their claims because they can sue insurers for bad faith and receive compensation for emotional distress and punitive damages under state laws governing their policies. An examination of the approval rate for individual LTD claims and the standard of proof required for success may reveal substantially more ethical -- and favorable -- handling of disability claims.

There are also powerful incentives for insurance company employees to deny claims: profitable companies pay substantial bonuses to employees who help them realize healthy profits. In February 1996, UNUM, the nation's largest disability insurer paid $18 million in bonuses to employees who contributed to the company's greatly improved performance in 1995.[2] And there is little doubt that ambitious claims managers can advance their careers by saving the company's money the best way they know how: by denying or closing claims.
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