Reasons Why Your Disability Income Insurance Claim May Be Denied
UPDATED: February 12, 2020
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What follows are some of the most common reasons your claim for long term disability income benefits may be denied:
1. No objective findings
The claim reviewer may deny your claim on the grounds that although you may be experiencing disabling pain, there are no “objective findings” to substantiate the disability. Basically, the claims reviewer likes hard, clear medical evidence (such as x-rays, MRI results, blood tests, and so forth) of some physical or mental problem. Some disability income policies specifically require objective findings; others do not …. and the insurer nevertheless asserts the absence of objective findings as a basis for denying benefits.
The courts are divided on whether a claims reviewer may legitimately require objective findings as a prerequisite for benefits when that requirement is not specifically mentioned in the insurance policy. A claim that is denied for this is a signal that it’s time to contact an attorney experienced in these matters who can review the file and the law to see if you have grounds for legal action against the insurer.
2. Not disabled from your occupation
When evaluating your ability to perform your occupation, the claims reviewer will often look at how the job is defined in the national economy as opposed to looking at the specific requirements of your particular job. Thus, the reviewer may deny your claim on the grounds that although your job may have uniquely strenuous or stressful requirements, the occupation generally does not have such requirements and, under those less demanding standards, you are not disabled. When making the determination, the claims reviewer may utilize generalized or even inaccurate job descriptions that do not properly reflect the actual requirements of your occupation. You need to be sure you obtain a clear explanation from the claims reviewer of the bases of the denial and if you have any concerns, you should contact an attorney who is an expert in disability insurance claims and ERISA.
3. Pre-existing condition exclusion
A pre-existing conditioncan be a reason for denying a disability insurance claim. The disability insurance policy may contain up to a 12-month pre-existing condition waiting period. A pre-existing condition is usually specifically defined in the policy as a medical condition for which you were actually treated within a specified number of months (for example, 3 months) before coverage began or for which a “reasonably prudent person would have sought medical care or treatment.”
4. Failure to fulfill the elimination period
Most policies have a requirement that a claimant be continuously disabled during an “elimination period” in order to be eligible for benefits. The elimination period is typically somewhere between 30 days and 6 months. Thus, although you may be totally disabled at the commencement of disability, if you do not remain totally disabled throughout the entire time covered by the elimination period, you will not be entitled to benefits.
5. Not under the care of a physician
Most policies require that you be under the “regular care’ of a physician. This is especially critical since you generally have to back up your claim with clear medical evidence. “Regular care” is frequently not defined and may be the subject of dispute. Another area of potential dispute is establishing what the insurer means by physician. Some policies attempt to clarify by stating that physician means medical doctor as opposed to alternative care providers. Other policies are not clear.
6. Not receiving appropriate treatment
Many polices pre-condition an award of benefits on you receiving “appropriate medical treatment.” This has raised a number of issues that have gone to litigation because it often results in an insurance company attempting to direct the medical care provided to you. For example, an insurer may insist on medical care that is at odds with that recommended by your treating physician as a pre-condition to paying benefits. Most courts have not supported this practice by insurers.
7. Self-reported symptoms
Some policies contain exclusions or limitations on disabling conditions that are based solely on “self-reported symptoms.” Such conditions may include headaches, dizziness or fatigue, symptoms that are often difficult to document by objective findings. Many times, however, an insurer may deny or attempt to limit liability on the basis of “self-reported symptoms” when the policy does not contain a specific exclusion or limitation pertaining to such disabilities. In such circumstances, it is possible for you to argue that the insurer is attempting to “re-write” the policy with exclusions or limitations that are not contained in the policy. To protect your rights, speak to an attorney who is a veteran in disability insurance claims before you make this argument.