About Disability Insurance Claim Denials
If an accident or illness prevents you from working, you may be eligible to file for disability insurance. Successful disability claims can lead to monthly benefits. Coverage may be available through the government, your employer, or private insurers.
If your disability claim is denied, you will receive a disability insurance claim denial via a letter. Claim denials prevent you from receiving disability insurance benefits.
However, even if your claim is denied, you may have options to fight the denial, like filing an appeal with help from an insurance lawyer.
Top 9 Reasons for Denial of Disability Benefits
Disability benefits are denied for many reasons. Here are the top reasons that your benefits may be denied.
1. Pre-Existing Condition Exclusion Through Your Insurance Company
Pre-existing conditions describe a medical condition that existed before starting a new health care plan. Conditions like chronic obstructive pulmonary disease (COPD), diabetes, and sleep apnea may be examples of pre-existing health conditions.
Before the passage of the Affordable Care Act (ACA) in 2010, insurance companies could deny you coverage or give you coverage at inflated rates if they determined you had a pre-existing condition.
The ACA has since made it illegal for health insurance companies to deny or inflate coverage rates based on pre-existing conditions.
However, if you are enrolled in a plan that started before 2010 (a “grandfathered” plan), these plans may charge you higher rates or cancel your coverage due to a pre-existing condition.
2. Disability Didn’t Occur at Work
If your disability happened outside of work, your claim may get denied.
Most health care plans cover disability that happens during a weekend, holiday, or regularly scheduled vacation, but some do not cover disability that happens during a leave of absence unless the leave is for medical reasons.
3. Failure to Satisfy the Elimination Period
Most healthcare insurance policies have an “elimination period” that can last 30 days to a year. You must be continuously disabled throughout this period to qualify for disability benefits.
If your condition improves during the elimination period, the insurance plan administrator may believe you are no longer disabled, even if you still can’t work.
4. Not Keeping up With Primary Care Physician Visits
Most disability insurance policies require you to receive regular physician care. As such, if you are enrolled in these plans, your disability claim may be denied if you stop seeing your primary care doctor and specialist(s) after a while.
If you love health insurance coverage, you can keep up with primary care physician visits by visiting a free clinic. You may also be eligible for reduced-cost or free Medicaid health care coverage.
5. You Have a Limited-Duration Benefits Condition
Some healthcare plans have two-year limitations on benefits for “subjective” disabilities caused by nervous and mental conditions, such as soft tissue disorders and chronic fatigue syndrome.
Even if you are totally disabled and have the evidence to prove it, your benefits can be terminated if your plan administrator believes your disability is contributed to or caused by a limited-duration benefit condition.
6. Lack of Evidence of Restrictions and Limitations
Health care plans often require you to submit objective evidence of the restrictions and limitations caused by your disability. Your claim may be denied if you have missing or insufficient medical evidence.
You can obtain this evidence by regularly obtaining laboratory test results, clinical findings, and imaging studies of your disability.
These results must be as specific as possible. Your doctor can’t just say you cannot work — they must show that your disability prevents you from working.
For example, if you developed a traumatic brain injury from a car crash that affected your cognitive abilities, your doctor should include evidence of your impairment. They should also estimate how much you can work per day or week.
7. Not Submitting the Claim Within the Deadline
Another reason for rejection is a missed deadline.
Most insurance policies have strict deadlines for when a claim must be filed. Typically, you must file proof of loss within 30 to 90 days after the date of the disability. However, each state has different requirements, so be sure to check with your insurer.
Additionally, you may be able to submit your claim after the deadline if you have evidence that you were mentally incapacitated (i.e., severely depressed) during the period in question.
8. Changes to Your Disability Definition
Most group disability insurance policies define “disability” as being unable to perform your occupation for 24 months (the “own occupation” definition).
Afterward, they will use the “any occupation” standard, which defines disability as the inability to perform any job you are qualified for based on your education and work experience.
9. Pending Medical Procedures
Finally, your disability insurance claim may be denied or postponed if you have a pending medical procedure. This is because the insurer wants proof that your pending procedures won’t lead to disabilities. Extensive surgeries can have life-altering consequences, such as loss of motor ability and sepsis.
Who Can Benefit from Disability Insurance?
Anyone whose injuries or illness prevents them from working can benefit from disability insurance. Disability benefits can help you with the cost of caring for yourself when you’re unable to work and your day-to-day living expenses.
If your disability insurance claim is denied, talk to a disability insurance lawyer. Your attorney will listen to your case and determine your next steps.
Eligibility for Disability Benefits
Eligibility for disability benefits depends on your specific disability insurance plan. For example, to qualify for the government’s Social Security Disability Insurance (SSDI), you must:
- Have worked in jobs covered by Social Security
- Have a medical condition that meets Social Security’s definition of disability
Generally speaking, people must show that they are “totally disabled” to receive long-term disability benefits. To prove that they are totally disabled, people must show that they cannot work or engage in substantial gainful activity due to their medical condition.
Talk to your healthcare insurance provider to learn more about your eligibility for disability benefits. Your provider can also explain disability insurance denial reasons.
Medical Conditions That Qualify for Disability Insurance
Medical conditions that qualify for disability insurance depend on the insurance plan provider.
Common medical conditions that qualify include:
- Bell’s palsy
- Bipolar disorder
- Cardiovascular disease
- Sleep disorders
Talk to your insurance provider to learn which medical conditions qualify for your disability insurance.
Short-Term Disability vs. Long-Term Disability Insurance Claims
A claim denial may also depend on whether you have short-term or long-term disability coverage. Short-term disability covers you immediately after a serious injury or illness, typically for a term of 3 to 6 months.
Meanwhile, long-term disability (LTD) gives you income replacement if your disability keeps you out of work after the end of your short-term disability benefit period. Some LTD benefits can cover claimants up to retirement.
Can You Appeal a Disability Insurance Claim Denial?
If you receive an initial denial, you can appeal the denial. Consult your denial letter or policy plan document for more information.
You may also want to talk to your disability insurance lawyer for more information. Your lawyer will explain how the claim process works.
Employee Retirement Income Security Act (ERISA) & Disability Benefits
Under the Employee Retirement Income Security Act (ERISA), you have a number of protections when filing for disability benefits.
This Act was established to ensure employees have access to:
- Insurance plan features
- Information about the minimum standards for participation, benefit accrual, and funding
- A well-established grievance and appeals process for plan benefits claims
In other words, employers provide their employees with accurate and clear-cut information about plan benefits, including disability insurance. When they don’t, you can appeal the denial.
If your disability claim is subject to the federal Employee Retirement Income Security Act (ERISA), you must appeal the denial in a timely manner (which could be anywhere from 60 to 180 days). If you don’t do this, you may lose the opportunity to file an appeal.
How to Appeal a Disability Insurance Denial
Receiving a disability insurance denial can be daunting, especially if your treatments are expensive. Follow these steps to appeal your disability insurance denial.
1. Investigate the Reason for the Claim Denial
First, investigate why your claim was denied. Read the claim denial letter to see why you were denied and to learn the deadline for the appeal. If the insurance company didn’t send a denial letter, ask them to put the denial in writing.
2. Find a Copy of Your Long-Term Disability Insurance Policy
Next, find a copy of your long-term disability insurance policy. This document will help you understand the denial and plan your appeal. Focus on the part of your policy that describes your disability benefits and eligibility.
3. Reach Out to a Disability Lawyer
Finally, you should reach out to a disability lawyer. Although it’s technically possible to appeal a disability insurance denial by yourself, working with the right disability attorney can significantly increase the chance of a successful appeal.
A trusted disability lawyer is well-versed in federal law, administrative appeals, long-term disability appeals, federal court processes, and negotiation.
They can walk you through the appeal process, gather and preserve vital evidence (such as medical records and medical evidence), and handle your claim file, giving you more time to recover from your illness and injuries.
Find Help for a Disability Insurance Claim Denial
If you or a loved one have received a disability insurance claim denial, reach out to LawFirm.com.
We make it easy to take legal action by providing lawsuit guides, information about disability insurance and personal injury issues, and connecting you with trusted law firms.
Call (888) 402-1587 to book a free consultation with a lawyer or law firm in our network. Our lawyers have helped many clients with their short-term and long-term disability claims and earned them just compensation.
Disability Insurance Denial FAQs
Why would disability insurance be denied?
A short-term or long-term disability policy can be denied for various reasons. The most common reasons for denial are:
- You have a pre-existing condition exclusion according to your insurance plan.
- Your disability didn’t happen at work.
- You were not continuously disabled throughout your plan’s “elimination” period, which can last 30 days to a year.
- You failed to keep up with primary care physician visits.
- You have a limited-duration benefits condition.
- You lack evidence of restrictions and limitations imposed by your disability.
- You didn’t submit your claim on time.
- There have been changes to your disability definition.
- You have pending medical procedures.
- Social media pictures or texts contradict your disability insurance claim (i.e., you claim to be totally unable to move for long periods, but you are posting pictures and videos of yourself taking hikes.)
Talk to your LTD policy lawyer to learn more about your short-term or long-term disability denial.
What disabilities are hard to prove?
Disabilities primarily characterized by subjective symptoms are harder to prove.
Examples of these conditions include:
- Fibromyalgia, a disorder characterized by widespread musculoskeletal pain accompanied by sleep, fatigue, mood, and memory issues
- Combinations of multiple mental and physical impairments that make it impossible for you to work
- Mental disorders such as depression
- Painful and degenerative physical disabilities such as those caused by back injuries
Fortunately, treating physicians can produce evidence to prove your disabilities and medical treatments.
Can you sue your insurance company for denying your disability benefits?
If you believe your insurance company has wrongfully denied your claim for long-term or short-term disability benefits, you may be eligible to start legal action against your insurance company.
A legal action allows the court, an independent third party, to review your case. This means your claim has a higher chance of being perceived differently.
Meanwhile, if you appeal an insurance company’s denial, you are leaving the appeal up to the company’s employees and internal processes to review your case again.
However, filing a lawsuit may be more expensive and time-consuming. It may also be more stressful. Talk to your LTD claims lawyer to learn whether you should file an appeal or sue your insurance company.