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Why Did Your ERISA Disability Claim Get Denied?

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When you signed up for your long-term disability plan from your employer, you expected it to be there for you if you got sick or hurt. Now that the worst has come about, you were relying on that disability plan to provide you with the income you need to keep your family going—but your claim was denied.

What happened? Most long-term disability policies are governed by the Employee Retirement Income Security Act, known as ERISA. ERISA claims are usually handled by the insurance companies, rather than an outside claims examiner. Since the insurance companies don't want to pay, claims get denied.

What Justification Do Insurance Companies Use to Deny Claims?

There is almost an endless number of ways that insurance companies try to use to deny valid claims, but some are more common than others. Your claim can be denied because:

  1. Your doctor's letter was missing. Sometimes doctors don't respond to requests for information fast enough, and insurance companies rush to deny claims before they can.
  2. Your doctor's statement was unclear. Any vague statements or a lack of detail regarding your limitations can be used to justify a denial.
  3. You don't have enough medical evidence. Insurers expect you to prove that your sick or hurt and trying to get well, so you have to show that you're continuing to seek treatment.
  4. You don't meet your plan's definition of "disabled." Some plans will approve you if you're unable to do your own job, while others require you to be unable to do any work at all.

Any of these reasons can result in a quick (if unfair denial), forcing you to go through a laborious appeals process.

Why Else Can Your Disability Claim Be Denied?

Even if you do everything right when you file, there's still a possibility that your long-term disability claim will be denied. It's not uncommon for insurance companies to hire private investigators to scope out a disability applicant's day, hoping to catch them doing something that discredits their application. 

If you have a back injury, for example, they may try to catch you on camera lifting a package that's been delivered to your house or carrying groceries from your car. Even if you just happen to be having a good day and the bags are very light, they will decide their video of a single moment is proof you aren't disabled.

If your long-term disability claim is denied, make no mistake: You should get the help of a disability attorney to fight back. Appeals have tight deadlines, and it may ultimately be necessary to sue the insurance company in court.