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Short-Term Disability: Responding to a Denied Claim

Facing a denial of your short-term disability claim can be distressing, but it’s important to know that denials can often be challenged and overturned through internal appeal or litigation. Even if the insurance company initially denies your disability coverage, it doesn’t mean you’re not disabled or that the decision is final. It is common for disability insurance providers to reverse their decision to deny your benefits upon further action taken by you or your counsel.

Typical Reasons for Claim Denial

Filing for short-term disability benefits can be challenging, and claims are denied for various common reasons. Understanding these common denial reasons can help you avoid these trends and assist in guiding how to respond to them. More importantly, due to the commonality of the reasons for denial, disability lawyers are very familiar with the best ways to respond to any given denial.

Here are some frequent causes for short-term disability claim denial:

1. Lack of Adequate Medical Evidence: Insufficient documentation from healthcare providers can lead to claim denial. It is difficult for healthcare providers to know what particular information will be required by the insurer, but at a minimum is it important that your healthcare providers are providing thorough reports of your disabling symptoms and your limitations to your insurance company. A simple sick note will be insufficient.
2. Pre-existing Conditions: Some polices exclude coverage for pre-existing conditions. The policy will contain very specific wording for timing of symptom onset and types of conditions that can fall under a pre-existing condition exclusion. If your disability is deemed pre-existing, your claim may be denied.
3. Failure to Meet Eligibility Criteria: Ensure you meet eligibility requirements outlined in your policy, including employment status and active work requirements. For example, it is important that you are actively employed at the time of your disability onset. It is common for claims to be denied when disability claims are brought by an employee after they have been terminated and the onset of disability is unclear.
4. Discrepancies in Documentation: This is typically experienced when there are inconsistencies between your claim forms and medical records that raise concerns for insurers on the veracity or accuracy of the records, resulting in a denial.
5. Non-compliance with Treatment Plans: Failure to follow prescribed treatment plans or refusing medical interventions without valid reasons can lead to claim denial.
6. Late Filing or Missed Deadlines: Timeliness is crucial in the claims process. Missing deadlines for filing or providing documentation can result in automatic denial.
7. Claiming Non-Covered Conditions: Some policies exclude coverage for certain conditions or circumstances. Claims for non-covered conditions will likely be denied.
8. Disputes Over Causation or Severity: Insurers may dispute the cause or severity of your disability, leading to claim denial if not adequately addressed.
9. Policy Interpretation and Legal Issues: Differences in policy interpretation or legal disputes can result in claim denial. Seeking legal assistance may be necessary to resolve such issues.
   All of the above common reasons for denial are rebuttable. Understanding the specific reasons for your claim denial, and the appropriate response, is crucial for formulating an effective appeal or effectively prosecuting your lawsuit. Our lawyers at Weir Bowen LLP, have extensive experience responding to the most common and the most obscure reasons for denial. We can assist you in developing the most appropriate approach for your situation.

Should You Appeal a Denied Short-Term Disability Claim?

Facing a denied short-term disability claim can be challenging. If you're unsure whether to appeal, consider seeking guidance from experienced lawyers in disability law to develop a tailored strategy. These professionals will consider key points such as:

1. Evidence Strength: Evaluate the evidence supporting your claim. If you have strong medical evidence, with minimal other issues raised by the insurer in the denial, internally appealing may be worthwhile.
2. Financial Impact: Consider the financial impact of the denial. If you’re struggling financially without benefits, appealing could be necessary. The counter point here is that an appeal denial will only act to delay your lawsuit and potential financial recovery.
3. Success Likelihood: Assess the likelihood of a successful appeal based on your case’s merits.
4. Time and Effort: Understand the time and effort required for the appeal process.
5. Proceeding Directly with a Lawsuit: An experienced lawyer will assist in balancing the pros and cons of filing an internal appeal versus skipping the appeal and proceeding straight to a disability lawsuit. Every situation is different, but it is important to know that many cases are complex and would benefit from a direct lawsuit instead of proceeding first with an internal appeal.
6. Alternative Options: Explore other financial support options if appealing isn’t feasible.

Ultimately, the decision to appeal depends on your unique circumstances. It is most common for counsel to recommend skipping an internal appeal and proceeding straight with a disability lawsuit, however, on occasion it might make sense after consultation to proceed with the internal appeal first. Consulting with legal professionals can help you make an informed choice and pursue the best path forward for your situation. At Weir Bowen, our experienced disability law lawyers are equipped to provide guidance and support throughout the appeals process, ensuring your rights are protected and maximizing your chances of a favourable outcome.

Our team at Weir Bowen LLP is knowledgeable in Disability Law and is here to assist you when you are in need. Contact us for personalized guidance and support throughout the claims process.