Denying ERISA claims based on misrepresented medical reportsInsurance companies will do almost anything to deny claims. After all, that’s how they make money! But one of their dirtiest tactics is using your doctor’s own words against you. You may think you have an ironclad claim for long-term disability (LTD) based on your medical report, but insurance adjusters are well trained in picking apart those reports to get just what they need to deny your claim.

We take a look at how claims with substantial medical evidence can be rejected.

Taking Just What They Need

The first thing the LTD insurance company will do is review all your medical records. Even if your doctor concludes that you're 100 percent disabled and unable to work, the insurance company will go through the entire report to find statements it believes are contradictory.

For example, if your doctor has released you to do some exercise, the carrier could interpret that as meaning you're regaining your physical abilities and should be able to return to modified work.

Misrepresenting Your Functional Capacity

Your doctor may be asked to fill out a long-form assessing your ability to do all kinds of things, from heavy lifting to sitting for extended periods. Even if your doctor believes you shouldn't return to any work, they may indicate that you're capable of sitting with no restrictions, and that could be enough for the insurance company to insist that you're able to return to full-time work.

Using Their Own Evaluators

If the insurer doesn’t like what your doctor has to say, it could send your medical records to an in-house consultant or an "independent" medical examiner. These doctors are motivated to contradict your doctor and will find any reason to do so. They may claim the diagnosis was based on subjective considerations or find some other reason to disagree with the conclusions of the treating physician.

How an ERISA Attorney May Be Able to Help

When a claim on a long-term disability policy you have through your employer is denied, you have to follow some specific and restrictive procedures to get this decision overturned. Learn more by requesting our free book, Don’t Go It Alone: How Insurance Companies Sabotage Disability Claims.

In the meantime, call the Monast Law Office to find out if our ERISA attorney can help you get the long-term disability benefits you deserve. 


James Monast
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Board-Certified Workers’ Compensation Attorney in Columbus, Ohio
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