Denied LTD benefits by UNUM?
Condition Improved: Long-term disability insurers under ERISA have the option of referring their insureds to a physician for an in-person exam or performing a “paper” review of the medical records to determine whether that person is “disabled.” Typically, insurers do a paper review where there is no in person examination conducted, but a doctor or nurse who has been hired by the insurer reviews the insured's medical records and concludes their condition is not as severe as the treating doctors say it is. The opinion of the physician or nurse is then used to terminate or deny benefits.
Condition Pre-Existing: Long-Term Disability (LTD) policies that are governed under ERISA frequently have a pre-existing condition coverage exclusion that is usually broadly worded. It often goes something like this:
“We will not pay any benefit, or any increase in benefits, under the policy for any disability that results from, or is caused or contributed to by a pre-existing condition, unless at the time you become disabled, you have not received medical care for the condition for 90 consecutive days while insured under the policy, or if you have been continuously insured under the policy for 365 consecutive days. “
Insurers often use pre-existing condition exclusions in the policy to avoid paying LTD benefits for a disabling condition by claiming its symptoms or manifestations occurred in the look back period, or to avoid paying for expensive treatments, by claiming substantial contribution from a prior pre-existing condition. These denials can potentially be challenged
"Other Work" Can be Performed: a common point in time where insurers deny/terminate benefits and which is made on the basis that after having conducted a review of the record, (updated medical documentation, and possibly an additional medical provider(s) hired by the insurer), that the insured can perform "some work" or "other work" in the national economy. In other words, even though the insured may not be able to perform his or her past work, there are other less strenuous (physically and mentally) jobs that exist. Bear in mind that if the insurer makes this determination without consultation or analysis from a vocational, medical expert or a change in the medical condition, then this may stand to be challenged.
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