There are any number of reasons an insurance company can use to deny benefits, limited only by the imagination of the claims representative. Of course, the insurance policy itself is a fertile ground for ERISA denials.
An insured has to realize that the entire policy is designed to state reasons for ERISA denials. It is actually hard sometimes to find the language by which the insurance for disability is afforded.
Nonetheless, there are certain bases for ERISA denials which come up more often than others. The first is a process whereby the insurance company has it’s on staff nurse “cherry pick” through the medical records to find reasons to discount clear findings of medical pathology and conclude that the claimant is simply not disabled. This approach has to be combated through evidence generated from a cooperative treating physician or physicians.
Another popular basis for denying claims is after benefits have been paid for a period of time, there is a change in the definition of the “own occupation” to “any occupation” which is a process the insurance company will try to support by use of its in-house vocational rehabilitation “expert” who attempts to identify a few jobs which the claimant can do even though the treating physician has clearly stated that work is contraindicated due to the injury or disease process which disables.
Third-way insurance companies try to reduce what they owe is to contend that a claim is based on a “mental/nervous” condition which usually has a two (2) year (or shorter) benefit payout. The language of the policy has to be carefully reviewed to ascertain the precise circumstances in which such a benefit limitation applies. This is why the first step is undertaken at my law firm to secure a copy of those documents called the Plan Documents which outline the benefit entitlement.
Other bases for denying benefits include notice of the claim, pre-existing conditions, inadequate medical documentation, improper offsets of “other income,” and others. Here at Herbert M. Hill, P.A. we have dealt successfully with all of these defenses over the many years we have handled these claims. We are prepared to present your case in the most favorable light to enhance every possibility of securing the benefits in the most timely manner possible.
