Why Do Disability Claims Get Denied?

Denied Disability Claims

If you have been denied your disability insurance benefits, you are likely feeling frustrated, overwhelmed, angry, hopeless, and don’t know what to do. There are a number of reasons why disability claims get denied. A few common reasons include the pre-existing exclusion clause, incomplete claim forms, and insufficient medical evidence.

Group Disability Insurance benefits (benefits provided through a group policy through your workplace) usually contain a pre-existing exclusion clause for Long Term Disability Benefits. This clause does not usually apply to entitlement to short-term disability benefits, so you may have received those, but your long-term disability benefits may have been denied because of the Pre-Ex clause. In short, this clause allows your claim to be denied if you have only had coverage for a short period of time (usually less than one year) and have been suffering with the same medical condition in the past during a period that will mean that you cannot obtain your LTD benefits.This clause is included to protect the insurance company from having to provide benefits to individuals they would not otherwise have ever insured had medical disclosure occurred at the time you were hired. It may seem unfair, but it is mandated by the applicable insurance legislation.

In some cases, there may be a way around it, but this requires review and examination by an expert lawyer in disability insurance. Before you give up, it may make sense to have an experienced disability lawyer here at Share Lawyers review your situation to see if there is any chance of avoiding the Pre-Ex clause.

A response from the insurer that they are unable to make a final decision because information is missing from what has been submitted, is obviously very frustrating and hard to see as anything other than a delaying tactic.

If this is the reason for the denial or “non-decision”, the first thing to check is whether there is something that can be done to provide the missing or erroneous information. It is important to complete these forms as completely and accurately as possible to avoid this type of response.

In some cases, the request is for additional information not necessarily included in the initial forms, such as copies of health care providers clinical notes and records, medical test results, financial information, and the list goes on.

In many cases, it is hard to feel like there is no way to ever provide all of the information the insurance company says they need to make a decision. If you fall into that category, it may be time to consult with a disability insurance lawyer about whether the ongoing requests for information are reasonable, or they are just delaying the inevitable decision to deny your claim outright.

We see this reason frequently and it is probably the most frustrating one for claimants because, what they’re really saying is that they are not satisfied that whatever you are suffering with is serious enough to prevent you from going to work.It could be that your medical information is not emphatic enough about the reasons you cannot work, but in our experience, your doctors are probably as frustrated as you are in understanding what else they can provide that would substantiate the reasons for not being able to work. In many cases, if you go back to your doctor and ask them for more assistance, they may say, ‘what else is there for me to say’?

If you have filed a disability claim and it has been denied, you are probably unsure of what to do next. Keep in mind that simply because your claim has been denied, this does not mean it is invalid. In fact, denying a disability claim is a commonly used tactic. While private insurance companies are tight-lipped about their claim-denial rates, government data offers an insight into the prevalence of the phenomenon. Denial of your disability claim should not be seen as the end of the road for you or your claim. You may feel disheartened, but you should by no means abandon your claim. It’s encouraging to know that workers with every conceivable injury or illness, from all walks of life, have had disability claims denied. These include physicians, dentists, engineers, lawyers, and even insurance professionals. These individuals were unable to do their jobs and forced to use their disability insurance, only to find their claim was denied.

People contact us at various stages of their claim process, but where your claim has been denied, we encourage you to contact us as soon as you have received a denial letter or e-mail advising you that your benefits are being denied or terminated. Usually these denials advise that you have a right to appeal these decisions within a specified time. In our experience, most people find these denial letters upsetting and confusing with respect to the applicable deadlines to appeal or dispute the decision that has been made.

Our best advice is to not delay contacting us when your claim has been denied. The initial call or e-mail to our office is free and once you have provided us with a sufficient amount of information we can discuss the next best steps for you.

Regarding deadlines, the information in the denial letter can be rather confusing and it is important to be sure that you haven’t missed any deadlines that could prevent you from being able to pursue your claim. Very often the denial letter says you must appeal within 30 – 60 or 90 days and provide additional information from your doctors in order to have the insurance company reconsider their decision. These deadlines are not usually written in stone, but they should not be ignored if you intend to proceed with your claim.

The ultimate deadline for taking legal action is usually longer than 30-90 days that is sometimes mentioned in an insurer denial letter. It is a good idea to err on the side of the earliest possible date rather than the outside date to avoid missing any deadlines. To understand what the limitation period is in your particular case you should consult with a lawyer so that there are no surprises.

In short, the sooner you contact Share Lawyers following a denial from the insurance company the better so that you don’t prejudice your claim due to a missed deadline.

Watch Our Video:

See what Brad Pleavin, an experienced lawyer here at Share Lawyers, has to say about the “common reasons why insurance companies deny long terms disability claims”.