Insufficient medical evidence leads to long-term disability denial

Many Wisconsin residents have long-term disability insurance policies through their employers. Despite the fact that the terms and administration of these plans must comply with federal law, long-term disability insurers are notorious for denying claims.

Often, when a disability claim is denied, the claimant can successfully fight the denial and obtain benefits with the help of an advocate. This is because these claims are often denied for questionable reasons. These cases are often very complicated, and a case that has now made its way to a district court on the East Coast is a good example of this.

In this case, a man had a long-term disability plan through his employer that said it would offer him disability income up to the age of 67 if he became disabled before the age of 62. But, under the plan, disability benefits would be limited to only 24 months if the worker was disabled because of neuromusculoskeletal or soft-tissue disorders. However, six specific conditions were excluded from this provision.

The worker became disabled in 2007 in a car accident. He was then granted disability benefits, but only under the 24-month limited provision.

The man appealed this decision twice, and argued that he actually had multiple conditions that qualified him as disabled. Additionally, he said he had radiculopathy, one of the specific conditions excluded from the provision.

A district court, however, reviewed the man’s medical records and disagreed with his arguments. The court said the medical records did not establish that he had radiculupathy and the court said the insurance administrator was within its right to only provide benefits for 24 months.

In some cases, insurers force claimants to see insurer-friendly doctors, which makes it hard to obtain benefits. When someone is denied benefits because of a lack of objective evidence, he or she is often wise to talk to a long-term disability attorney about options.

Source: Bloomberg BNA, “Limitations Provision Upheld Against Long-Term Disability Plan Participant,” Sept. 25, 2012

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