Insurance companies often cite a lack of consistency in the conduct and statements of a claimant, misrepresentation of medical facts, and insufficient medical proof when denying short-term disability claims. The presence of a pre-existing condition, lack of a qualifying disabling condition, and ability to delegate duties are other common reasons short-term disability can be denied.
If you have received a denial despite having a qualifying disabling condition, you might want to know the reasons a short-term disability claim can be denied. Each short-term disability claim is unique. The reasons for denial vary from one claim to another. Fortunately, you have a legal right to appeal short-term disability insurance claims denials. A knowledgeable disability lawyer can help you prepare and file a strong appeal to increase the likelihood of your short-term disability benefits getting approved.
What Is Short-Term Disability?
Short-term disability insurance is part of employment benefits offered by many employers in the U.S. The duration of short-term disability coverage varies from plan to plan. Coverage can last anywhere from a month to 12 months. Your specific injury or illness will determine how long you will be unable to work. Your treating doctor will use medical guidelines to predict the length of your recovery journey.
Whether your health problem qualifies as a short-term disabling condition will depend on the terms of your policy. A short-term disability plan will generally cover non-work-related injuries or illnesses that keep you from performing your job. It may, for instance, cover an injury caused by an accident or a chronic illness that needs a long treatment period.
Short-term disability insurance covers a percentage of your salary when you cannot work for a limited time frame due to a non-work-related injury, illness, or health issue. Note that this type of temporary disability does not generally fall under workers’ compensation insurance. The latter covers work-related injuries.
The amount you will receive while on short-term disability will depend on your policy. Some plans cover 100% of your salary. Most short-term disability plans, however, provide between 50% and 60% of your average weekly wage.
Reasons Short-Term Disability Can Be Denied
Insurance companies commonly prioritize generating profits over their clients’ well-being. Your insurance company may employ unfair tactics to deny or delay processing an otherwise valid claim. The goal is to frustrate you into abandoning your rightfully owed benefits. The following are common reasons short-term disability can be denied:
Lack of Consistency in Your Conduct and Statements
An insurance company may use your conflicting statements or actions as grounds for denying your short-term disability claim. An insurance agent may trick you into saying something that might give the impression that your injuries are not serious enough. Your insurer can use such statements to justify your claim denial.
Your insurer may also hire a private investigator to monitor your offline and online activities. The investigator can follow you and take pictures or videos of you participating in restricted activities. Such forms of evidence can hurt the chances of your claim getting approved. The investigator can also monitor your social media updates to gather the information that can help your insurer to discredit your disability.
Inaccurate or Insufficient Information on Disability Insurance Application
Your insurer may cite the presence of incorrect or inadequate information on your initial disability insurance application as a justifiable reason for denying your claim. The insurer may further claim that it has a right to revoke your coverage based on that reason.
Your lawyer can help you contest this denial by showing that inaccurate or inadequate information does not affect your coverage. The insurer, for instance, cannot deny your claim just because your initial application contains an incorrect phone number or email address.
Insufficient Evidence to Prove Your Disability
An insurance company may cite insufficient medical evidence to prove your disabling condition as a reason for denying your claim. Support your short-term disability claim with as much medical proof and other evidence as possible to maximize the odds of an approval.
Be sure to include well-prepared accident reports, witness statements, medical test results, prescription records, and relevant medical records. Also, include a detailed report from your treating doctor explaining how your condition impacts your ability to work.
These documents contain your health and personally identifiable information. Consult your disability lawyer if you are worried about releasing such information to your insurer. The lawyer will guide you on which information to share and which to protect.
Having a pre-existing health condition is another reason short-term disability can be denied. In this case, a pre-existing health condition is any illness or physical complication for which you obtained treatment, medical opinion, or medication within the first 12 months of your short-term disability coverage. An insurance company might deny your claim if a pre-existing medical condition causes your disability.
Lack of a Qualifying Disabling Condition
Each short-term disability plan has its unique definition of a disabling condition. Some plans consider you disabled if you cannot do the essential duties of your job. Other plans deem you disabled if you cannot complete the essential duties of any job in which you have the required training, academic qualification, and expertise.
Some plans may exclude certain health problems, such as mental health issues, from coverage. Other plans may exclude some disabilities and cover their symptoms. The definition of disability under your coverage will determine if you have a qualifying condition.
A disability lawyer can examine the terms of your policy to determine if you have a qualifying injury, sickness, or symptom. The lawyer can ensure your medical records and doctor’s report accurately describes your disabling condition. This strategy helps you stand a better chance of securing approval.
Ability to Delegate Duties
The ability to assign your duties to other employees is one of the most common reasons short-term disability can be denied. Your insurer may claim that you can assign your duties to another staff member until you recover from your disabling condition. The insurer may further claim that transferring duties to another worker will not affect your career.
The ability to delegate specific job duties is not a justifiable reason for denying your claim. You have the right to appeal such a denial. You can initiate a bad faith insurance lawsuit against your insurer if necessary. A lawyer who is experienced in handling these types of cases can help victims recover fair bad faith claim settlement amounts.
Missed Deadlines and Mistakes During Filing
Almost all group and individual short-term disability plans have deadlines that claimants must meet. They also have procedures that claimants must follow when initiating a claim. Missing the filing deadline or failing to satisfy all policy requirements may cause a denial of your claim.
Carefully review the terms of your policy to familiarize yourself with the relevant deadlines for your claim. Ensure you adhere to all your policy requirements when filing a claim. Alternatively, let your disability lawyer handle this process for you to avoid making costly mistakes.
Can You Challenge a Short-Term Disability Claim Denial?
You have the right to appeal a short-term disability claim denial. ERISA appeals involve complicated and strict procedures. Even a small mistake can cost you your disability benefits. Hiring a lawyer who handles disability claims denials, and following these steps, can help improve your chances of achieving success in your appeal.
Familiarize Yourself With the Appeal Process
Learn the relevant procedures and deadlines for filing an appeal immediately after receiving a short-term disability claim denial. You might find this information on the claim denial letter from your insurance company. You can also request that information from your insurance company via phone call or email. The deadline for appealing is usually 60 days. Missing the deadline for appealing could later prevent you from challenging the denial decision.
Determine the Reason for Your Claim Denial
Check out the denial letter to determine why the insurer denied your claim. If the denial letter lacks any reason for your claim denial, call your insurer and ask for this information. Obtain a copy of your original short-term disability contract and review it. Determine whether the denial reason provided by your insurer is justifiable based on that review. If not, you might have grounds for challenging the denial decision.
Gather Sufficient Evidence to Strengthen Your Claim
The reason for your claim denial will help you determine the type of evidence you need to collect. You may obtain additional medical records from your doctor and a second opinion from an independent medical provider. You may obtain written statements from your colleagues regarding your disabling condition. Incident reports and surveillance footage are also essential forms of evidence for injuries caused by slip and fall accidents.
File Your Appeal
Submit your appeal together with all the necessary supporting documentation to your insurer. Be sure to submit all the evidence that might help your case when appealing an ERISA disability claim. The reason is that only evidence presented during the appeal will be admissible at trial if a lawsuit is needed to resolve your insurance dispute. In other words, ERISA rules bar you from adding new evidence at trial.
Get Legal Support
As you have seen, the appeals process can confuse someone with no legal background. Working with a disability lawyer with a record of resolving short-term disability denials can increase your chances of securing an approval.
Your lawyer will review your original claim and policy documents to determine whether the reason specified in the denial letter is justifiable. The attorney will identify the additional documentation necessary to strengthen your claim further. He or she may advise you to get examined by another doctor other than your treating doctor. The attorney may also ask you to complete additional testing, like residual functional capacity.
A disability insurance attorney will discuss statutes, procedures, and deadlines applicable to your claim. The attorney will ensure your claim is compliant and error-free. The attorney will poke holes in the evidence presented by your insurer to maximize the chances of a successful appeal.
Your disability lawyer will take your case to court if the insurer rejects your appeal. The lawyer will present compelling evidence and arguments to support your case. This process may involve calling a vocational expert witness to explain your job requirements. It may also involve asking an expert medical witness to explain the impact of your disabling condition on your ability to work.
When Should You Hire a Short-Term Disability Lawyer?
The best time to hire a lawyer to handle your short-term disability case is soon after suffering a disabling condition that might prevent you from working for a limited period. The lawyer will look at the specific details of your case and advise you on the steps to take.
Don’t wait until you receive a claim denial to hire a lawyer. Involving a lawyer at the initial stages of your claim can help safeguard your rights and interests. It can also allow you to focus on your recovery rather than worrying about deadlines and other legal issues associated with the claims process.
Generally, a disability lawyer will offer you a free phone or in-person consultation or case review. This offer allows you to “shop around” until you find a lawyer who inspires confidence in you.
Don’t worry about the cost of a disability lawyer when thinking about the reasons short-term disability can be denied. These lawyers usually have contingency fee structures. Under these fee structures, you must win the case to pay the lawyer. A contingency fee structure specifies the percentage of your recovery your lawyer will deduct as legal fees. It also specifies who will pay litigation-related costs and how they will get paid. Be sure to review and understand the terms of your lawyer’s contingency fee structure.
Chicago personal injury and workers’ compensation attorney Howard Ankin has a passion for justice and a relentless commitment to defending injured victims throughout the Chicagoland area. With decades of experience achieving justice on behalf of the people of Chicago, Howard has earned a reputation as a proven leader in and out of the courtroom. Respected by peers and clients alike, Howard’s multifaceted approach to the law and empathetic nature have secured him a spot as an influential figure in the Illinois legal system.