The Employment Retirement Income Security Act (ERISA) is a federal law which governs Cigna disability and other long-term disability insurance plans offered by private-sector employers.

Most people are insured through their employers and apply for the benefits purportedly guaranteed them through Cigna disability or other long-term coverage have qualifying health conditions. However, these long-term disability claims may be denied.

Why are long-term disability benefits important?

You are probably wondering why long-term disability benefits are important if they are so difficult to “cash in” on when the need arises. The U.S. Census Bureau estimates that one out of every five people is at risk for becoming disabled, according to The Balance Careers.

The average length of time of this disability or illness — assuming it is not permanent — is 2.5 years. Even with a sizable savings account, the inability to work and bring in money over this period of time likely would render a family destitute.

What is the difference between long-term disability and worker’s compensation?

Workers’ compensation is often confused with long-term disability insurance. The former, however, only assists you if you are injured or your beneficiaries if you are killed on the job. Injuries that occur on personal time (off the clock) or not on the work premises do not qualify for this coverage.

Workers’ compensation helps cover medical expenses connected to the injury, pays a portion of the lost wages when you can’t work, and retraining costs if you must learn to do a different job within the scope of your post-injury abilities.

Long-term disability insurance is more comprehensive in that it covers you for injuries that occur in any setting and at any time. It will replace part of the income lost due to the inability to work, and it can last for years.

Why are so many long-term disability claims denied?

The short answer is that insurance companies are in business to maximize profits. When they have to pay claims, that cuts into insurers’ profit margin — so there is a lot of incentive to delay and deny rightful claims.

Administrators who work for the insurance company in the vast majority of cases are the ones to evaluate claims for disability, and this arrangement may be unfair to the applicant from the start.

Some allege that insurance reviewers have a conflict of interest and desire to have the best outcome for the insurer rather than the insured may sway the decision-making against the employee.

A number of companies that provide long-term disability may have made it a point to deny rightful claims, even going so far as to provide incentives for employees to find reasons for denying and terminating claims by people who have paid their premiums in good faith for years.

The fact is that many long-term disability claims are denied for seemingly minor reasons that are usually found in the fine print. Claims adjusters go through an insured’s claim with a fine-toothed comb in order to find any possible reason for denial.

This is one reason that it is advisable to have an experienced attorney representing you when you wind up having to file an appeal for disability with Cigna or whatever insurance carrier you have been with.

How does inadequate medical evidence play a role in denial of benefits?

By far the most common reasons a Cigna disability or other long-term disability claims adjuster would give for denial falls along the lines of inadequate medical evidence. This could be because of a failure to get regular medical care in the form of visits to a general practitioner or specialist or because records of those visits have been transmitted haphazardly.

Regular care needs to be sought in proportion to the condition and objective lab or other testing performed to back up visit notes. The patient should be asking for a printed copy from the insurance company regarding which records they have received with dates of service and work to make sure the notes from all visits are completely in the hands of the claim administrator.

Finally, seeking and ensuring that your doctor has provided her or his own written statement on your condition is vital. Insurance companies may provide forms that are designed to get responses that won’t support the insured’s claim. This is why one should not rely on the forms provided for this statement by the disability insurance provider.

What are other reasons for denial?

There are several other major reasons why claims may be denied:

• Video surveillance. Insurance companies will hire private investigators to spy on claimants. If footage shows the claimant engaged in activities that appear to belie their claims of disability, that can be grounds for denial. This may also include posts on social media.
• The insurance company’s doctor disputes your own doctor’s diagnosis. Believe it or not, insurers hire their own physicians to examine claimants and not surprisingly, they will usually disagree with your own doctor’s conclusions about your disability. The only way to fight this is to prove that your own doctor’s findings are more reliable than that of the company doctor.
• The insurance company disagrees on what is considered a “disability.” It is a good idea to read the declarations in order to see just how your insurance company defines a disability. If it affects your “own” occupation and you can no longer carry out the duties of your specific job, you may be considered disabled. If on the other hand, the policy refers to “any” occupation, and you are deemed to be able to do a different job, you may be denied.

What should I know when I file an appeal for disability with Cigna?

Whether you are dealing with Cigna or another provider of LTD insurance, a denial is not a reason to stop fighting. Some of the things you can do:

• Review the denial letter to determine why your claim was denied
• Make certain you have up to date medical records
• Get testimony from friends, family, co-workers, supervisors as well as medical professionals
• Make a note of any deadlines as missing a deadline can be used as reason for denial

Above all, get legal help. Filing an appeal for disability with Cigna or another insurance company is a complicated process that is best done with the assistance of qualified legal counsel. Insurance companies have virtually unlimited resources, but they are not invincible. A qualified attorney experienced in filing appeals can maximize your chances of receiving the payments to which you are entitled.

The insurance appeal process can be a complicated and stressful process, so Top Class Actions has laid the groundwork for you by connecting you with an experienced attorney.

Get help with your long-term disability insurance appeal

If an insurance company denied your long-term disability insurance claim within the past 180 days, a knowledgeable insurance attorney can help you appeal.

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