Disability Claim Denied: Reasons and What Next

Nobody desires to ever make a disability claim because it is a stressful procedure. As well, being denied benefits when disabled can place you in a difficult situation. Unfortunately, disability and denial of disability claims are real and happening every day across Canada. If your claim is denied, do not fret; there are ways for you to conquer your denied claim.

Reasons why Your Disability Claim may be denied

Sometimes the insurance company may deny your claim without a good reason. However, some claimants are also to blame for making unconvincing claims. Remember that the insurance company must ensure that only airtight cases succeed, otherwise it may soon be insolvent. It is your responsibility to proceed in a manner that the company will not have doubts about the legitimacy of your claim. If at some point you are denied, you may appeal or sue the company successfully. Consider the following common reasons for denial of disability claims:

Lack of Objective Medical Evidence

Your disability claim may be denied if it is not supported by objective medical evidence. You should ensure that your doctor gives you a report that accurately communicates the reality of your situation. Some illnesses like fibromyalgia, migraines and chronic fatigue syndrome cannot be proven by diagnostic tests. There is no medical device that measures the amount of pain or fatigue – even though chronic fatigue syndrome and chronic pain are legitimate disabling conditions. If your claim is denied, do not give up, you still have other options to pursue.

Material Misrepresentation

The insurance company is entitled to deny your claim if, at the time of purchasing the policy, you failed to disclose important medical information. This only applies if you have purchased a personal disability insurance.

Contractual Eligibility

Group policies usually have eligibility criteria. Some may require you to have been actively employed for a certain number of hours before being eligible to receive disability benefits.

Pre-existing Conditions

Many disability policies exclude payment for disability arising from a pre-existing condition. A medical condition is pre-existing if you suffer from it before being insured under the policy. Your group insurer will usually deny your claim on this ground if you become disabled within one year of becoming insured under the group policy.

Policy Exclusions

Long term disability policies have a list of exclusions. For example, the company will not pay your claim for disability arising from:

  • Intentional self-inflicted injury
  • Commission of a crime or involvement in an illegal act
  • Participation in a riot or war
  • Use of drugs or alcohol.

What to do when your disability claim is denied

If the insurance company purports to deny your disability claim on any of the above grounds or any other grounds, do not give up. You could pursue an internal appeal or file a lawsuit. This is the right stage to consult a disability claim lawyer if you had not retained one from the onset. The lawyer will advise you on the most appropriate course of action.

In Appealing a Denied Disability Claim, You Should:

  1. Understand the Reasons for Denial. The first thing is to understand why your claim has been denied. This is the only way you can lodge a successful appeal. Get written reasons for the denial and a copy of the company’s internal claim file to ensure that you see all the information that the company has and you do not have.

  2. Understand the appeal process. Each company has its own internal appeal process which may be outlined in the policy booklet. Usually, the letter of denial will inform you of your right to appeal within a specified time. Make sure you appeal within that time, otherwise, your appeal will be time barred.

  3. Fill the Gaps in Your Initial Application. To succeed in a disability appeal, you should identify the gaps in your initial application and try to fill them. These gaps could relate to clarification of functional limitations, clarification of a medical diagnosis, clarification of job requirements, provision of additional medical evidence and clarifying your work history.

  4. Have a Game Plan. You should know what you want to achieve with the appeal and get the necessary documentation to help you in this process. You may need to prepare written submissions to demonstrate how you have filled the gaps and why the previous reasons for denial should not apply. It is advisable to have a lawyer to increase your chances of success.

The Response

After submitting your appeal, you only need to wait for a response which could be coming in less than a month. If you lose the appeal, it’s still not over, you could commence litigation against the company if your lawyer advises that your claim should not be denied.