The process of filing a disability claim can be challenging, and, unfortunately, many applicants face denial. Understanding the common reasons behind these denials can help you prepare your claim more effectively. The California Disability Insurance Lawyers at Kantor & Kantor LLP share ten of the top reasons your short-term or long-term disability claim could be denied.
Wrongfully Denied Disability Claims
Our attorneys understand the opposition because we have experience working for insurers. This unique perspective allows us to recognize their tactics to underpay, delay, and deny claims. More importantly, we know how to counter these tactics and protect your rights. Here are the most common reasons insurance companies wrongfully deny disability claims.
1. Insufficient Medical Documentation
One of the primary reasons for claim denial is a lack of comprehensive medical documentation. Insurance companies require clear and consistent medical evidence to support your claim. This includes:
- Detailed medical records from your healthcare providers
- Diagnosis and treatment notes
- Test results and imaging reports
Make sure your documentation thoroughly explains your condition and its impact on your ability to work.
2. Failure to Meet Policy Definition of Disability
Disability policies often have specific definitions of what qualifies as a disability. If your condition does not meet the criteria outlined in your plan, your claim can be denied.
- For short-term disability, you may need to demonstrate that you are unable to perform your regular job duties.
- The criteria for long-term disability may be more stringent, often requiring you to prove that you cannot perform any job for which you are reasonably suited.
3. Pre-Existing Conditions
Many disability insurance policies contain clauses regarding pre-existing conditions. If your disability arose from a condition that existed prior to owning the policy, your claim might be denied. Review your policy for “pre-existing condition” exclusions and ensure you understand any waiting periods that may apply.
4. Insufficient Work History or Coverage Issues
Some short-term and long-term disability policies require a minimum work history or duration of coverage before you can file a claim. If you have not met these criteria, your claim may be denied. Ensure you are aware of eligibility requirements in your policy and check for any contractual waiting periods.
5. Noncompliance with Treatment Plans
Insurance companies expect claimants to actively pursue treatment for their disabilities. If you are not following through with prescribed treatments, attending therapy sessions, or taking medications, your claim may be at risk. Keep records of your treatment compliance, and if you have valid reasons for noncompliance, document those as well, as they can be crucial during the appeals process.
6. Fraud or Misrepresentation
Any indication of fraudulent activity or misrepresentation of your condition can lead to immediate denial. Insurance companies conduct investigations and may review your social media and public records. Always provide accurate and truthful information on your claim and avoid exaggerating your condition.
7. Employment Status Changes
Changing jobs, becoming self-employed, or being terminated from your position before filing a claim could impact your eligibility. Claims must often be filed while actively employed or within a certain period after employment ends. Ensure that you understand your coverage and filing deadlines, especially after any changes in employment status.
8. The Condition is Not Covered by the Policy
Private and ERISA long-term disability plans have specific exclusions regarding certain medical conditions. Notably, coverage is typically denied for issues related to drug or alcohol abuse, self-inflicted injuries, or those resulting from criminal activities. Be aware of these limitations when considering your coverage options.
9. An Independent Medical Examiner Disputes Your Disability
Insurance providers may request an independent medical exam (IME) if they have concerns about the severity of your disabling condition. The insurer typically selects a physician with a history of siding with their interests to perform the examination. This chosen doctor may lack the necessary training or specialization to accurately assess your specific condition and might not have access to all your medical records.
10. Insurance Provider Error
Disability insurance claims representatives possess varying levels of experience, which can occasionally lead to errors in the claims process. Claims administrators representing the insurance company may deny a claim prematurely, sometimes without reviewing all available evidence. If your claim is denied, requesting a thorough explanation to understand the reasons behind the decision is important.
Experienced Policyholder Representation for Denied Disability Claims
Understanding the reasons behind disability claim denials is essential for a successful application process. Before submitting your claim, it may be beneficial to consult with an experienced attorney who can help guide you through the complexities of your specific policy and ensure that you have all the necessary documentation in order.
If your claim is denied, remember that you have the right to appeal. Kantor & Kantor LLP can help you navigate the appeals process effectively, providing support as you seek the benefits you deserve. For any questions about your long-term or short-term disability claim, don’t hesitate to ask for assistance. Your financial security and well-being during a challenging time is paramount.
