I am Already Receiving SSDI, so Why Was my LTD Claim Denied?
While a disability claim approved by the Social Security Administration (SSA) does not automatically mean your Long-Term Disability (LTD) claim will also be approved, it is very concerning when one’s LTD claim is denied in light of an SSDI approval. This is because the SSA typically has a much more stringent definition of disability than a traditional LTD policy.
What to Do If Your SSA is Approved and Your LTD is Denied:
Get a copy of both the LTD policy and the denial letter. Look for and highlight any mention of your SSDI benefit in the denial. If the denial fails to mention your SSDI benefit or only has a mere mention of your SSDI approval without going into much more depth, this can be relevant and useful should you need to sue your LTD provider to enforce your ERISA protected benefit.
In Montour v Hartford Life & Acc. Ins. Co, the plaintiff Mr. Montour faced this exact mismatch of findings when he was found “totally disabled” by SSA but his LTD benefits were denied by the Hartford.
In Montour, the Court explained that the scrutiny the SSA uses for a disability claim is typically higher and more stringent than any LTD policy because SSA looks to see if a person can do any sort of work within their age, education, and ability – not just the job they have become unable to do. So, when an LTD provider makes a denial despite an SSA determination of “totally disabled,” the onus shifts back to the LTD provider to justify their contrary finding. And “[o]rdinarily, a proper acknowledgment of a contrary SSA disability determination would entail comparing and contrasting not just the definitions employed but also the medical evidence upon which the decisionmakers relied.” Montour v. Hartford Life & Acc. Ins. Co. (9th Cir. 2009) 588 F3d 623, 636.
When courts review the discretionary decisions of LTD providers, they look at several factors to see if there was an abuse of discretion by the LTD provider. An abuse of discretion is usually highly deferential to the original decision maker. But, when a structural conflict of interest exists, the Courts have a much more critical eye when weighing the factors. An SSDI approval and LTD denial is vital evidence to provide to a judge reviewing an LTD provider’s discretion. Ultimately, for Plaintiff Montour, the Court found the Hartford’s failure to explain in detail how and why LTD benefits were denied despite the approval for SSDI led the Court to find that the Hartford did abuse its discretion when it denied Mr. Montour’s claim. The weighing of factors is a complicated standard to overcome, but an essential argument that a denied claimant should make if the facts fit the scenario. Just remember that evidence of an SSDI approval against an LTD denial can help tip the scales towards overturning a denial because it calls into question the decision-making process the LTD company made when denying benefits.
The LTD provider should also give a claimant a chance to perfect the record if additional information from a claimant’s SSA determination was not considered by the LTD administrator. Failure to allow a claimant to perfect the record can also be considered evidence of abused discretion by the LTD administrator.
Obtaining long-term disability benefits can be essential after a debilitating injury or diagnosis. It can be scary to hear your claim has been denied when you are counting on that benefit to make ends meet. Getting the right information and support from a knowledgeable attorney can prove to be not only sensible but also incredibly reassuring.
When you initiate a claim under this coverage, you need to be aware of your rights and responsibilities, which may necessitate legal counsel. At Bonnici Law Group, we offer you client-centered representation at all stages of the long-term disability benefit claims process with the support of a team – without any up-front fees or costs to get started. When you need the kind of help that only an experienced long-term disability benefits attorney can offer you, contact Bonnici Law Group at 858-261-5454 or firstname.lastname@example.org.