How to Fight a Denied Long-Term Disability Claim for Long COVID

As long COVID leaves millions struggling with persistent symptoms like fatigue, respiratory issues, and brain fog, many affected individuals have turned to long-term disability (LTD) insurance to secure income replacement. However, the path to a successful LTD claim for long COVID can be challenging, as many claimants encounter outright denials from insurance companies. For those faced with a denied LTD claim due to long COVID, knowing how to fight back is essential.

Here’s a detailed look at why long COVID claims are often denied and steps you can take to appeal and strengthen your case.

Why Long COVID LTD Claims are Frequently Denied

The persistent and sometimes vague nature of long COVID symptoms, combined with the relative newness of the condition, makes it challenging for individuals and healthcare providers to meet the rigid documentation standards often required by insurance companies. Here are a few common reasons why LTD claims for long COVID may be denied:

1. Insufficient Medical Documentation: Long COVID often manifests with symptoms that are challenging to quantify, such as fatigue, brain fog, or muscle pain. Without objective medical evidence, insurance companies may argue that symptoms are not severe enough to meet their definition of “disability.”
2. Subjective Symptom Claims: Because symptoms like brain fog and shortness of breath are subjective, insurers may claim there isn’t enough tangible evidence that these symptoms are disabling. This lack of clear diagnostic criteria and concrete measurements can lead to skepticism from insurers.
3. Complex Policy Language: LTD policies can be confusing, with specific requirements around the definition of “disability” that may not easily apply to long COVID. Some policies may require claimants to be unable to perform the duties of “any occupation,” a stipulation that is especially difficult to meet for those with fluctuating symptoms.
4. Preexisting Condition Exclusions: Some insurance companies may try to classify COVID-19 or long COVID as a preexisting condition, which could be excluded from coverage if the policy was purchased after the initial COVID-19 outbreak or if the policy excludes conditions that predate a certain timeframe.

Given these common barriers, here are some practical steps to help you appeal a denied long COVID LTD claim.

Steps to Appeal a Denied Long COVID LTD Claim

1.Understand the Reasons for Denial

The first step in appealing a denied LTD claim is to carefully review the denial letter from your insurance company. Insurers are required to provide specific reasons for denial, outlining areas where they feel your claim lacks sufficient evidence or fails to meet policy criteria. Understanding these reasons allows you to build a focused and comprehensive appeal.

Common issues cited in denial letters for long COVID include insufficient medical documentation, lack of objective test results, or failure to meet the policy’s definition of disability. Addressing each of these issues directly will be crucial for a successful appeal.

2.Gather Comprehensive Medical Evidence

Long COVID claims require a robust collection of medical documentation. Here’s how to gather the evidence needed to strengthen your case:

• Visit Specialists Regularly: Insurance companies may look for evidence that you are receiving specialized treatment for long COVID symptoms. Consulting specialists like pulmonologists, neurologists, or cardiologists can provide detailed records that demonstrate the impact of your symptoms on your ability to work.
• Keep Symptom Logs: Documenting daily symptoms, activity levels, and any limitations can help show the persistence and severity of your condition. Include details on days when symptoms worsen, as well as any activities that trigger or exacerbate symptoms.
• Obtain Functional Capacity Evaluations (FCE): An FCE performed by a licensed healthcare professional can objectively measure how long COVID symptoms affect your physical and cognitive abilities. This evaluation can be a powerful evidence of limitations that affect your capacity to work.
• Get Statements from Medical Providers: Ask your doctors and specialists to provide written statements that describe your symptoms, treatments, and prognosis. They should also detail how these symptoms interfere with daily activities and job functions.

3. Build a Strong Case with Objective Evidence

Since long COVID symptoms are often subjective, finding ways to include objective data in your claim can be beneficial. While it can be challenging to quantify symptoms like fatigue or brain fog, certain tests and evaluations can provide measurable evidence:

• Neuropsychological Testing: For claimants experiencing cognitive difficulties, neuropsychological testing can provide objective data on issues like memory, attention, and concentration.
• Pulmonary Function Tests: For those with respiratory symptoms, lung function tests can show measurable limitations, which are particularly useful if breathing issues impact your work capacity.
• Workplace Accommodations Evaluations: If you attempted to return to work with accommodations but found it impossible due to symptoms, documentation of these efforts can support your claim that long COVID prevents you from sustaining employment.

4. Consult an Experienced Disability Attorney

Navigating an appeal process can be complex and daunting, especially with long COVID claims where the burden of proof is high. Consulting with a disability attorney who has experience with LTD claims can provide critical support. An attorney can:

• Interpret Policy Language: Policies contain legal jargon that can be difficult to interpret. An attorney can explain the definitions and stipulations specific to your policy and help determine whether the denial was justified.
• Gather and Organize Evidence: Attorneys know what documentation insurance companies are looking for. They can coordinate with your medical team to ensure that all necessary records are gathered and presented effectively.
• Negotiate and Communicate with Insurers: Disability attorneys are skilled in negotiating with insurance companies. They can address insurers’ objections directly, challenging their arguments with relevant facts and evidence.

5. File Your Appeal Within the Deadline

LTD insurance companies set strict deadlines for appeals, often within 60 to 180 days of the initial denial. Missing this deadline can bar you from further pursuing the claim, so it’s essential to file on time. When filing, include a comprehensive appeal letter that directly addresses each reason for denial, referencing specific evidence for each.

6. Consider Filing a Lawsuit if Necessary

If your appeal is denied, you may pursue legal action. In many cases, a lawsuit can be filed in federal court under the Employee Retirement Income Security Act (ERISA) if your LTD plan is employer-sponsored. This legal route is often complicated, and it is advisable to seek legal representation to navigate it effectively. A lawsuit can sometimes lead to a settlement, reassessment of your claim, or a court ruling in your favor.

Understanding Your Rights and Moving Forward

Insurance companies may bank on claimants feeling overwhelmed and giving up after an initial denial. However, LTD claims denials are often successfully overturned when claimants take a systematic approach to gathering evidence, presenting a well-organized case, and enlisting legal support when necessary.

Long COVID claims may be challenging, but they’re not impossible to win. The growing body of medical research surrounding long COVID can be leveraged to substantiate claims, particularly when supported by medical records and expert statements. Taking proactive steps to understand why your claim was denied and directly addressing these issues is key to increasing your chances of success.

Long COVID presents unique and often debilitating challenges, making it difficult for many to maintain employment. If your LTD claim has been denied, it’s essential to fight back by organizing comprehensive medical evidence, gathering objective data, and considering legal assistance. Facing a denial can be discouraging, but with the right strategy and support, you can significantly improve your odds of overturning the decision and obtaining the long-term disability benefits you deserve.