Why Would a Disability Claim Be Denied

When you purchase an insurance policy, you expect the provider to pay your claim in the event of a covered loss. However, disability claims aren’t always straightforward, and your insurer may reject your submission. So, why would a disability claim be denied?

Pre-Existing Conditions

Many times, the insurance company will try and deny your claim using the pre-existing condition exclusion in the policy. Pre-existing conditions are typically those conditions for which you sought treatment or which a doctor suspected during the few months just prior to you becoming an insured under the disability policy. If you go out on disability during the first year you are covered under the disability policy you may want to look hard at that pre-existing condition exclusion in the policy.

We see pre-existing exclusion denials most often in those cases where there is a long-term struggle with a condition and your employer switches policies on you, or you purchase a new policy and go out on disability during the first year.

Anytime you are going out on disability or filing a claim on a new policy during the first year of coverage you need to read that policy very carefully. The insurance company is going to take a dim view of only collecting one year of premiums before they have to start paying a claim, and they will go in search of an exclusion if they can.

Incomplete Claim Documentation

We often hear people say that they had signed authorizations for the insurance company to go gather all the documents and medical records. That’s the first mistake. Don’t count on the insurance company to do the work for you. Written proof is necessary to support your disability claim. In addition to completing claim forms and signing authorizations, you should take steps to go gather the records yourself and ship them to the insurance company in a way that you can prove they got them. You need to gather all the documentation regarding your condition and disability to include:

Medical records
X-ray, MRI, and lab results
Chart notes
Prescriptions
Proof of income and employment history

The Condition Isn’t Covered or Doesn’t Meet Policy Guidelines

Every insurer has its own definition of disabled. As such, read the policy’s fine print to ensure you meet disability guidelines and qualify for insurance. Additionally, disability plans might exclude subjective complaints like migraines, chronic fatigue syndrome and depression, crime-related injuries, and self-inflicted disabilities.

Late Claims

Lateness may undermine the insurer’s rights or affect their ability to process your claim. You might also miss the opportunity to sue your insurer. The following deadlines are crucial to your claim.

Filing and appeal deadlines
Medical updates
Responding to insurer queries
Document submissions
Statutes of limitation

Disputed Disability From Independent Professionals

It’s not uncommon for insurers to order independent medical examinations from non-treating doctors to confirm the existence and severity of your disability. However, such exams could be biased because:

The insurer picks a doctor who has favored them in the past.
The doctor might lack the specialization to conduct a proper evaluation.
The doctor will most likely conclude your condition isn’t disabling, something your insurer expects.
The insurer may not submit all your medical records.