The application for a disability insurance benefit is the foundation for the entire claim. When a person calls us at Dell & Schaefer and says they already applied, we cannot undo that. But, if a person calls us weeks or months before they apply, we can help set the stage in a way that increases the chances of success of having Prudential approve the claim.
When you receive your disability policy from your employer, it is governed by federal laws under ERISA. Your whole claim file is based on paper documentation. This is true whether it is your medical information or your work information.
You only get one chance to make a first impression, and if the information is not presented properly to the insurance company, your claim will be denied. There is a balance that must be met between providing enough information to support your claim or providing too much information.
Unless you experience a catastrophic injury where it is pretty clear you are unable to work, you need to present your disability claim in the best possible light. An experienced disability lawyer can help you avoid the pitfalls many land in that results in a denied disability claim. Here are 5 top reasons Prudential denies claims presented for long term disability insurance benefits.
An experienced disability lawyer can help to avoid the pitfalls many land in that results in a denied disability claim. Below are the 5 top reasons Prudential denies claims presented for long term disability insurance benefits.
#1 The Claim for Disability Arises from a Pre-Existing Condition
Almost all Prudential disability policies have a pre-existing limitation that says that if you have been covered under the policy for less than 12 months and you file a claim for disability, a pre-existing condition review will be triggered. The review will look back 90 days, in a few instances, we have found it will go back six months, but 90 days is almost standard, to see if you have had any medical treatment for the condition on which you are basing your claim. If so, it will be deemed a pre-existing condition and your claim will be denied.
We have seen cases where a person has filed their claim for disability when they have been employed 364 days, which triggers the pre-existing condition review. If they had waited one more day, there would have been no review. A disability attorney should make sure that that kind of situation does not happen.
#2 Claimant Does Not Understand the Definition of Disability
Prudential is one of the top three insurance companies in the world. Its definition of disability for the first 24-months is almost always “the inability to perform the duties of your own occupation.” After 24-months, it changes to “the inability to perform any gainful occupation based upon your training, education, and experience.”
Depending on the type of coverage your employer provides, there may be an income component that requires you to be unable to earn 60 or 80 percent of your pre-disability income.
The policy will generally look at how your own occupation is performed in the national economy. This is often insufficient. In order to have your claim approved, you must provide information about your specific job duties and how your medical symptoms and condition makes it impossible for you to perform them. The failure to provide this information is often the reason for the denial of the claim.
#3 Incorrect Date of Disability
If you have had the condition for some time but continued working, Prudential will wonder what changed? It will ask, “How come you were able to work with your backache but now you can’t do that anymore?” Some people will file a claim when they have not seen a doctor for a while. The insurance company will say, what happened? What exacerbated your problem? Our doctors do not see anything wrong with you and you haven’t seen a doctor of your own.
If you are thinking about filing for disability, it might behoove you to take some time off. Call in and take a sick day. Use some vacation time. See a doctor. Wait to file your disability after you have received medical care and have documentation that you have a debilitating medical condition.
#4 Medical Records Do Not Support the Claimed Medical Condition
Many people have never looked at their own medical records. They just assume their doctors have written down what they have told them. Doctors treat patients and are less concerned about their charts and Prudential knows that.
Prudential will say, “Well, your doctor didn’t document these complaints you are telling us about now. You didn’t get pain medication, there was no range of motion evaluation. Your doctor didn’t mention anything about your difficulty in focusing, did not comment on your cognitive issues, etc.” If it is not documented in the medical records, then Prudential will deny your claim.
Prudential is also notorious for conducting video surveillance on claimants while evaluating their claims. They may capture you taking out the garbage and brining in the garbage cans. Maybe you are on video walking your dog. The company will say, “If you can do those things, you can do your sedentary job.”
Prudential’s claim representatives are not sophisticated. They don’t have the skills or experience to handle the 100 plus claims the company hands to them. They consult an occupational evaluation manual that may say after a back surgery, you should return to week in 12 weeks. Carpel Tunnel surgery? Return in three weeks. There is no personalization and decisions are made by rote.
We educate our claimants to educate their doctors about the importance of documentation in the medical records. When Prudential gets your claim, it needs to see that all the medical evidence supports your claim that you are unable to perform your specific job duties.
#5 Filing the LTD Disability Claim in Piecemeal Fashion
Claimants will often submit their documents in a piecemeal fashion. This is almost encouraged by the claim form Prudential sends for you to fill out. The same form is used for someone who has a lower back problem as for someone who has a heart attack.
The questions will be, “Can you perform sedentary, light, or medium work?” There is no place on the form for the doctor to provide additional, appropriate, or complete information. Often, the physician may just write “inapplicable.” The lack of information makes Prudential decide the condition must not be so bad since there is not very much information provided. Prudential may ask for more information, so you send in more. The process is repeated until your claim is eventually denied.
How a Disability Insurance Attorney Can Help
At Dell & Schaefer, we assist with filing claims with the goal of having approval with the first application. There is an appeals process and the ability to file an ERISA lawsuit when administrative remedies have been exhausted, but those all take extra time.
Call us at (888) 292-8481 to schedule a free telephone consultation. We will ask you to send us your policy and, if you have applied and been denied, we will need a copy of your denial letter. We will review these documents and then discuss with you whether we can help. A disability insurance lawyer will generally call you back the same day.
We help claimants nationwide. We do everything telephonically or through email so you are not inconvenienced by needing an office visit. We look forward to discussing your Prudential claim with you.