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ERISA • Employment Law

Possible Reasons Your Disability Claim Was Denied

26 Apr 2022

Many people who need disability benefits receive a claim denial from their disability insurance company. When this happens, you only have a short time to appeal the decision, and your appeal must comply with all requirements under the Employee Retirement Income Security Act (ERISA) for employer-sponsored coverage. 

The first step of an appeal is to review the reasons for denial, and the following are some common reasons why your claim might be denied. To discuss your specific denial, reach out to an experienced disability claim attorney directly. 

Not Filing on Time

Many policies have timeframes following your disability to start the claim process. If you fail to notify your insurance company of a new disability by the deadline, the insurer might deny your claim. 

Not Responding to the Insurance Company’s Inquiries

Some people might file a claim and assume they did what they needed to do. However, many insurance adjusters require additional information or documentation. Once you begin receiving benefits, the insurance company will need to verify your continued disability throughout the future, and you will need to provide continual information. If you fail to properly respond to these inquiries, the insurer can deny your claim or cut off your benefits. 

Pre-Existing Conditions and Other Policy Exclusions

Your policy will have exclusions that set out when the insurer will not provide benefits. A common exclusion involves pre-existing conditions, and if the insurer thinks that you knew about your condition shortly before purchasing your policy, it can deny benefits. 

Insufficient Evidence

The insurance company will require significant evidence of your medical condition and the fact that your condition is disabling and prevent you from working. If you fail to provide sufficient evidence to show you are eligible for benefits, you can have your claim denied. In addition, conditions with no objective medical evidence – such as fibromyalgia, chronic pain or fatigue, or some mental illnesses. Your insurance company might state a lack of objective evidence as a denial reason. 

Non-Compliance with Treatment or Medical Care

When you have a disability, you should keep up with all medical treatment to improve your situation whenever possible. If your condition improves and you regain the ability to work, you should return to work. If the insurance company thinks you did not comply with doctor’s orders or return to work, it can deny your benefits. 

Credibility Problems

You can bet the insurance company will investigate your credibility. The company might check social media or even surveil you to ensure you are not engaging in any activities that should be prohibited by your disability. Credibility questions can lead to a denial.

Change of Definition

If your policy starts as “own occupation” and then switches to “any occupation” after two years, you might lose your benefits. 

Speak with a Philadelphia Disability Lawyer Right Away

The Garner Firm, Ltd. helps with disability claim appeals, and we craft specific strategies based on your denial reasons. Please contact us for more information and a consultation today. 

Experienced Counsel

Mr. Garner is an ERISA employee benefits and employment attorney with over a decade of experience. The laws governing employee benefits, the employment relationship, and the workplace are complex.

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