Ameritas Long Term Disability Claim Denials
All disability insurers use external or internal physician consultants to evaluate benefit claims. The insurers present the medical opinions generated by these physicians as objective, independent, and therefore reliable. However, the reality is that many insurers repeatedly consult the same physicians for opinions that tend to favor the insurance company and disadvantage the insured.
The insurance industry has spawned an entire cottage industry to appease disability insurers’ demand for medical reviews. In the context of disability, workers’ compensation, health insurance, and personal injury litigation, a significant number of third-party vendors now provide review services exclusively to insurance companies and employers. These companies never offer their services to claimants because they rely solely on insurance companies and employers for revenue. They naturally provide reviews that enable customers to save money and encourage repeat business. Exam Coordinators Network (ECN), Genex, ExamWorks, ReedGroup, Dane Street, Medical Consultants Network (MCN), MLS Group of Companies (MLS), and Network Medical Review (NMR) are among the largest companies that utilize this business model.
Reasons Ameritas May Deny Your Claim
Many physicians who perform these insurance company reviews use the same justifications for denying benefits claim after claim, and insurers arguably know the outcome before receiving the doctor’s report. The actual reasons given by the physicians vary from case to case, but they are frequently plausible on the surface. Among the most prevalent justifications are:
- Alleging a lack of “objective medical evidence” to support reported symptoms or the extent of work restrictions;
- Ignoring or attempting to discredit the claimed symptoms of a claimant because they are “subjective” or “based on self-reports.” This occurs frequently with symptoms such as pain or migraines; “cherry-picking” Beneficial-sounding notations from the medical records, such as notes that the client is “improving” or that their symptoms are “getting better,” and taking them out of context to argue that these statements indicate the claimant is not disabled.
- Misrepresenting the medical evidence, such as objective medical test results, in order to conform to the insurer’s desired narrative;
- Contesting the claimant’s diagnosis and disregarding their reported symptoms; and substituting their own opinion regarding the claimant’s physical “restrictions and limitations” and rejecting the opinions of the treating clinicians, even when all other information is uncontested. The consultant physician’s restrictions and limitations are almost always less restrictive than those of the treating physician, but are typically just enough to ostensibly permit the claimant to return to work. In addition, if one of your treating physicians does not impose any restrictions or imposes only mild restrictions that would allow you to work, the consultant physician will frequently focus on this physician’s opinion, regardless of what your other doctors say.
Overcoming a plausible-sounding adverse medical review is one the most challenging aspects of the disability claim process. It requires medical knowledge and specialized legal experience. Oftentimes additional medical and/or functional testing can help overcome an insurance doctor’s rationales. It is also vital to have a treatment team willing to advocate for you and “set the record straight.” The experienced attorneys at Robinson Warncke routinely help to identify and arrange necessary objective testing, and we will work with your treatment team to ensure that your doctors provide a detailed and compelling response to any misinformation being asserted by the insurance medical consultants.
Denying Long-Term Disability Claims
If you have filed a claim with Ameritas and are unsure of when they will respond, you may be unsure of what to do next.
If you encounter any of the following, it may be time to consult with an insurance attorney.
- The insurance company requires a medical evaluation from a physician who does not specialize in your condition.
- The insurer denies the claim without conducting a sufficient investigation.
- The insurance company repeatedly requests the same information.
- The denial letter makes no mention of the evidence you submitted to the insurance provider.
- The insurance company has not rendered a decision within a reasonable timeframe.
- Not informing the claimant about what information is required to process the claim, or not informing the claimant about deadlines.
- The expectation of insurance companies is that policyholders will not dispute the decision. They rely on policyholders accepting inadequate settlements to prevent prolonging the claims process. If you have paid into a disability plan for several years and find yourself in this situation, you should be aware that the insurance company is taking advantage of you. You can and should defend yourself.
Consult an attorney before filing your administrative appeal.
In any disability claim governed by ERISA, you are generally obligated to file an administrative appeal once your claim has been denied. You only get one shot at an appeal, and it is the most critical phase of every claim. It is almost always a serious mistake to try to handle your own appeal. We have reviewed hundreds of claims that might have been won if the appeal had been handled correctly by an expert, but which end up being compromised by a well-meaning claimant who did not do a good job with the appeal. It costs you nothing to contact the attorneys at Robinson Warncke for a phone consultation. Let us help you determine whether your appeal can be won, and to come up with an action plan that can turn a claim denial into approved disability benefits that can cover your lost income for many years.