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What’s in Your Medical Records Can Affect Disability Claims

Arnett & Arnett, PC May 15, 2023

If you’ve been denied benefits from your Long-Term Disability (LTD) insurer either when you file your claim or after you've been receiving benefits, the insurer will try to cite reasons saying you are not disabled or are not disabled enough.   

They can rationalize this by using the information submitted by your doctor, requesting you to submit your full medical history to search for pre-existing conditions and other causes for your claimed disability, or by requiring you to undergo an “independent” examination by a physician or medical group of their choosing.  

If you are submitting an LTD claim, or have submitted one being challenged or denied for medical reasons in or around Chandler, Arizona, contact us at Arnett & Arnett, PC. Our attorneys have the knowledge to deal with LTD insurer tactics, which often are questionable if not outright “bad faith,” and we can help you press your case and mount an appeal if necessary.   

Our team at Arnett & Arnett, PC has 30 years-plus of experience in countering insurance company denials and limitations of earned benefits. We proudly serve clients not only in Chandler but also in Phoenix, Tucson, Flagstaff, and throughout Arizona. 

LTD Insurers and What They’re Looking For 

Most long-term disability (LTD) insurance policies contain exclusions for pre-existing conditions. These exclusions, depending on the policy, can last for three to six months or even up to a year. If your disability claim comes within that exclusionary period, the insurer can cite your pre-existing condition as a reason for denying your claim.  

If you have no pre-existing condition or passed the exclusionary period the insurer can still look into your medical records to find something to proclaim that you are not as disabled, despite what your physician’s statement claims. 

Two Prominent LTD Insurer Tactics: Parsing Your Medical History and Cherry Picking 

LTD insurers are for-profit businesses. This means they have every incentive to limit or deny your benefits. Two ways they can do this is by “cherry picking” from the physician statement you submit with your claim and by requesting you to submit your medical history to them.  

During a cherry-picking tactic, the insurer will look for phrases or sentences in your physician’s evaluation that they can literally “bend” to their end to deny or lowball your claim for LTD benefits.   

For instance, you’ve had a stroke, and your physician proclaims you’re unable to work. The insurer has its team of medical examiners look through your physician’s statement. The examiners find a statement mentioning that you can sit in a chair for hours on end while recovering. From this, they proclaim that you can work in a sedentary job and thus are not unable to work.  

The second tactic is to request your medical history. If they do this, politely decline and seek a disability claims attorney if you don’t already have one. The insurer will search your medical history for anything they can use to claim your disability does not prevent you from working, whether it’s from finding a recent pre-existing condition or another reason.   

Another tactic is to request what’s called an independent medical examination (IME), which means the insurer will send you to a physician or medical group of their choosing to conduct an evaluation of your condition, separate from that of your own physician. Naturally, they will pick “independent” medical examiners who tend to favor the company that hires them. 

The Phone Call: Beware 

LTD insurers – in fact, all insurers, including your auto policy people – will employ claim adjusters to interview you about what happened, and in LTD cases, about your condition and your ability to work. They will act nice, but their goal is to get you to say something that they can use to conclude that you’re not really disabled, or at least not as much as you claim.   

Sometimes, the company will even switch claim adjusters on you midstream to prolong the process, hoping you will just give up. Of course, this practice goes against the Employee Retirement Income Security Act (ERISA), which sets standards of performance, but the average policyholder probably will not realize this. ERISA, however, applies only to LTD policies you purchase through your employer. If you purchase a policy on your own, state laws apply. 

What to Do If Your Claim Is Denied 

If your claim runs into difficulties or is denied, either initially or after you’ve begun receiving benefits, you need to seek the counsel and guidance of an experienced disability claims attorney. If you have an ERISA-covered policy, which the majority are, that federal statute covers the appeals process, but it generally favors the insurer even though “employee” is part of the law’s title.   

Your first appeal is administrative, which you must make to the insurance company within 180 days of your benefits denial. During this appeal, you can supply additional evidence to bolster your claim.  

If the administrative appeal fails, you can file a lawsuit to challenge the decision, but under the terms of ERISA, you cannot submit any additional evidence, medical or otherwise. The lawsuit must be based on evidence submitted during the administrative appeal. This means that during the administrative process, you must “load the record” with medical and vocational evidence favorable to your case. 

Turn to Reliable Representation 

If you’re making an LTD claim, or if your claim is running into difficulties or has been denied, you need to seek the counsel and representation of an experienced disability claims attorney. Our team at Arnett & Arnett, PC, has 30-plus years’ of helping individuals navigate the LTD claims process and mount appeals when claims are denied.   

We will work with you from start to finish to make sure you assemble the most comprehensive medical and vocational evidence, along with testimony by coworkers, family members, and others, to bolster your claim and improve its chances of success. When it comes to an appeal, we will work with you to create a strong package of evidence to counter any assertions by the insurer.   

Reach out to us with all your LTD insurance questions and concerns wherever you are in Arizona.