It is an unfortunate reality that many disability insurance claims are denied. Some of these claims truly are without merit, but many valid claims are denied because of simple mistakes or missing information. In my experience as an insurance claims attorney, the most common (and largely avoidable) issues that may lead to the denial of your initial claim for benefits are:
- You Don’t Have a Clear Diagnosis or Objective Medical Findings.
Sometimes, a patient may have severe symptoms, but no diagnosis. Certain conditions, like multiple sclerosis (MS), Lyme Disease or inflammatory bowel disease (IBD), are not always diagnosed immediately. Instead, patients are given a “possible” diagnosis for a long period of time before testing shows a definitive, fact-based diagnosis.
Other times, a diagnosis may be based on the patient’s subjective complaints, instead of diagnostic testing. Fibromyalgia is a good example of this type of diagnosis. Many disability insurance plans require objective (or fact-based) evidence in order for a claimant to be awarded benefits. If you do not have a medical diagnosis or objective findings (like an MRI) that easily explain your symptoms, the insurance company may deny your claim.
- You Did Not Follow the Doctor’s Orders.
It is important that you see your doctors regularly and consistently, and follow their recommendations to the best of your abilities. Sometimes, a disability claimant will be denied benefits because he or she failed to follow a doctor’s treatment recommendations. The compliant patient will be awarded benefits more often than the non-compliant patient.
- The Insurance Company Did Not Get All of Your Medical Records.
When you apply for disability insurance benefits, the insurance company will have you sign a medical records release (or HIPAA release). Your medical records are an important part of your disability claim. These records will help the insurance company understand the severity of your conditions and your work restrictions. However, the insurance company may not order all of your records or may make a decision before receiving a complete copy of your medical records. Sometimes, these missing records contain important information that supports your claim.
If your disability insurance claim is denied, you should request a full copy of the insurance company’s file. You (or your insurance claims attorney) can review the insurance company file for completeness. It is important to add missing information to the insurance company’s file. Once your claim is appealed to the federal court, you cannot add additional evidence to the record.
- You are Able to Perform Some Work.
In order to receive benefits, you must prove that you are disabled. ERISA plans define disability in two different ways: “own occupation” plans and “all occupation” plans. Under an “own occupation” plan, you are disabled if you cannot perform your job. Under an “all occupation” plan, you are disabled if you are prevented from doing any job. If you are covered by an “all occupation” plan, you must show that you cannot do even the simplest and lightest jobs. This can be difficult to prove, especially if you have some residual abilities. Additionally, many plans shift from “own occupation” to “all occupation” when you become eligible for long-term disability benefits. Sometimes, this change results in a sudden denial of benefits.
- The Insurance Company Questions Your Credibility.
Insurance companies are for-profit companies, and do not want to pay out benefits. If, in the eyes of the claims adjuster, your medical records show inconsistent symptoms, “drug seeking” behaviors or perceived malingering (exaggerating your symptoms for financial gain), the insurance company will use this as an excuse to deny benefits.
Likewise, if you minimize your symptoms, this also could result in a denial of benefits because:
- Your doctors may not understand the severity of your conditions, and their records will not support a conclusion of disability; and/or
- The insurance company may conclude that you are able to work because, in understating the impact of your symptoms, you have overstated what you can do in terms of daily activities.
Accordingly, the best practice is to give honest and accurate information to your doctors and the insurance company.
- You Have a Pre-Existing Condition.
If there is evidence that your medical condition pre-existed your disability insurance coverage, your claim may be denied. Many ERISA plans have up to a 12-month waiting period for pre-existing conditions.
- Your Disability Was Short-Lived.
Most, if not all, ERISA insurance plans require that you be disabled for a period of time in order to receive disability benefits. Typically, this time period is somewhere between 30 days and six months.
Before you apply for disability insurance benefits, review your Summary Plan Description (SPD) for your plan’s durational requirements. The SPD is a document that sets out your insurance plan’s terms and conditions for disability benefit eligibility. The rules in the SPD can differ greatly from plan to plan, so make sure you have a copy of your current SPD (and not an older version).
- You Failed to Complete Forms or Attend a Medical Examination.
Many ERISA claims are denied because of non-cooperation. During the claims process, you may be asked to complete questionnaires, undergo examinations and provide information. If you do not comply with these requests, your disability insurance benefits may be denied.
It is best to cooperate with the insurance company and provide honest and accurate information. If you are uncomfortable with an insurance company request, or do not understand a form, contact an insurance claims attorney for help.
- Sometimes, There Isn’t a Good Reason.
Disability insurance companies are for-profit businesses. They tend to deny more disability claims than they approve. You may have a legitimate claim and still get an initial denial of benefits. If your disability insurance claim has been denied, contact an experienced insurance claims attorney right away. Most ERISA plans have strict deadlines for filing an appeal (often 180 days). If you do not file an appeal within this timeframe, you will be barred from receiving disability insurance benefits.
ERISA claims are complicated; they involve a great deal of paperwork and recordkeeping, and demand attention to detail. It is easy to make mistakes. A skilled and experienced insurance claims attorney can guide you through the process and give you the best chance of winning your claim. If you would like to talk about your situation, please call me or click the Free Claim Analysis button at the top of this page.