It can be highly frustrating when your long term disability insurer denies your disability claim. There are several common reasons why your claim may have been denied. By understanding them, you may be better able to appeal the denial and receive the benefits you deserve. The following are the most common reasons disability claims are denied:
1. A Lack of Objective Findings to Support your Claim
Claims reviewers sometimes deny disability claims, stating that there are no objective findings to support them. What this means is that the reviewer does not have hard data, such as x-rays, lab results, MRIs or other medical tests in order to support a physical or mental health diagnosis. In some cases, a claims reviewer will use lack of objective evidence as a reason to deny you claim even though this is not a requirement in your insurance policy. In that case, you may need to get help from an attorney who is experienced with denied disability claims.
2. Denials Based on Your Job Not Causing Your Disability
In some cases, a claims reviewer will utilize inaccurate occupational information or national statistics in order to say that while your job may have certain strenuous requirements, those requirements do not apply industry-wide and thus, you are not disabled under the lower standard. If you receive this type of denial, it is important that you request that the claims reviewer of their basis for arriving at this determination.
3. Pre-existing Conditions Denials
Your claim may be denied if your disability claim is based on a condition or symptoms for which you received treatment during a time period of exclusion listed in your policy. It may also be denied if the reviewer determines that your non-treated condition is one that you reasonably should have sought treatment for.
4. Not Being Disabled for the Entire Elimination Period
Most long-term disability insurance policies include something called an elimination period, which generally lasts from between 30 days and six months following the onset of your disability. If a policy holder does not remain totally disabled during the entire elimination period, their claim will be denied on that basis.
5. Not Receiving Treatment from a Doctor
Almost all disability insurance policies will require policy holders to receive ongoing treatment from a doctor. This is important for you to do anyway, as you will need good medical documentation in order to support your benefits claim. There are a couple of problems that may arise with this requirement, however. First, how often you are supposed to see your doctor may be at issue, as policies seldom define the meaning of ongoing care. Second, some policies do not describe the type of doctor that is allowed, while others will state that the physician must be a medical doctor. If you have received care from an alternative medicine practitioner, your claim may be denied on the basis that you did not receive treatment from a physician with the required credentials.
6. Deeming Your Treatment as Inappropriate
There have been cases in which an insurer makes recommendations that go against the doctor’s recommended treatments. The claims reviewer then uses that as a basis to deny a claim. Although insurance companies may attempt to control a policyholder’s treatment in this manner, they have been largely unsuccessful in resulting court litigation.
7. Claims Based Only on Self-Reported Symptoms
While some policies expressly exclude claims based on self-reported symptoms, such as chronic pain, fatigue, or dizziness, many policies do not. If your claims reviewer denied your claim because your disability diagnosis was based on such symptoms, you may be able to argue that the reviewer is attempting to rewrite your policy if an exclusion is not contained within it.
Contact an Attorney for Help with Your Denied Disability Claims
You should remember that insurance companies are in the business of making money, and they have an incentive to deny claims in order to avoid payouts. Just because you receive a denial does not mean that you are not entitled to benefits under your policy. In order to successfully appeal a denial, you may need help. For your denied disability claims, contact an attorney at Hiller, PC – Attorneys at Law to schedule your consultation by calling toll-free at (212) 319-4000 today.