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7 Common Reasons Why Your Disability Insurance Claim Could Be Denied
21July 16

7 Common Reasons Why Your Disability Insurance Claim Could Be Denied

Our New Jersey disability insurance attorneys describe common reasons why insurance companies deny disability insurance claims and explain how you can reduce the chances that your claim could be denied for one of them.

  1. Lack of Objective Findings

Insurance companies often deny disability claims when the diagnosis of a condition is based upon self-reported symptoms, such as pain (e.g. fibromyalgia, migraines or chronic headaches), fatigue (e.g. chronic fatigue syndrome), depression, or anxiety, rather than objective medical evidence, such as X-rays, MRI scans, or blood tests.  When there is no clear medical evidence of some physical or mental problem, insurers are inclined to believe that the claim is exaggerated or fraudulent.

If your condition is subjective in nature (based largely on self-reported symptoms), our experienced New Jersey disability attorney suggests that you provide the insurer with additional evidence, such as:

  • A diary. Your diary should record your symptoms (even on a good day), how your symptoms affected your activity, whether you needed to see a doctor or urgent care, if you had to miss or leave work early, and what may have caused the onset of your symptom or aggravated your symptoms.
  • Witness statements. Statements from your family, friends, co-workers, supervisors, and employers regarding your condition and how it affects your daily and work activities could also provide persuasive evidence that your condition is disabling.
  1. Insufficient Medical Evidence

Your disability claim may be denied if you provide insufficient medical evidence.  The following are common deficiencies in medical evidence that can lead to a denied claim:

  • Lack of regular treatment. If your condition is truly debilitating, then your medical records should indicate that you are receiving regular treatment.  A break in treatment could show that your symptoms are not actually severe.  Whether you suffer from a physical or mental impairment, you should be seeking treatment regularly and following your doctor’s advice.  Additionally, for physical impairments, you should be receiving objective tests (e.g. radiological exams, blood or urine tests, etc.) whenever possible to support your diagnosis and show the progression of your condition.
  • Missing medical records. Sometimes, disability claims are denied because the insurer did not have all of the claimant’s medical records.  Our knowledgeable New Jersey disability lawyers recommend providing the insurer with your relevant medical records to ensure that the insurer has your complete records.
  • Doctor’s statements and opinions. Your treating physician’s opinion is compelling.  Our seasoned New Jersey disability attorney will request that your treating physician provide a report detailing your medical history, your symptoms, your diagnosis and supporting medical evidence, your work-related medical limitations, and prognosis.
  1. Failure to Meet Your Policy’s Definition of “Disability”

Disability insurance policies may define “disability” as being medically unable to carry out the duties of:

  • your “own occupation,” or
  • “any occupation.”

If your policy defines disability as an inability to perform your “own occupation,” then you are disabled if you cannot carry out your duties in your current or most recent occupation.  However, the insurer may look at how your position is defined in the national economy as opposed to your specific duties for your job.  Therefore, even if your job has uniquely strenuous or stressful requirements, if the occupation generally does not have those duties the insurer may deny your claim.

If your policy defines disability as “any occupation,” then you are disabled if you are unable to perform the duties of any job to which you are reasonably suited by virtue of age, education, and experience, a much more difficult standard to meet.

To improve your chances of success, you may need to be evaluated by a vocational expert and you may need to provide a detailed analysis of your current job, your prior work experiences, and your education.

  1. Policy Exclusions

Your disability insurance policy may exclude certain conditions, such as conditions related to substance abuse or pre-existing conditions.  A pre-existing condition is usually defined in your policy as a medical condition for which you were actually treated within a specified number of months prior to the coverage start period or for which a “reasonably prudent person would have sought medical care or treatment.”

For conditions based on self-reported symptoms, your policy may either exclude those conditions or limit your benefits to 24 months.

  1. Failure to Fulfill the Elimination Period

To be eligible for benefits, your disability insurance policy may require you to be continuously disabled during an “elimination period,” typically between 30 days and six months.  If you are not totally disabled during the entire time covered by the elimination period, you will not be entitled to benefits.

  1. Video Surveillance or Photographs Inconsistent with Disability Claim

Insurers have been known to hire investigators to take photographs, video surveillance, or to otherwise investigate claimants.  They could follow you and photograph or take video of your activities, or they could conduct a media or social networking search for any photographs or videos of you participating in an activity that is contrary to your disability claim.  You may have been having one of your “good days” as opposed to your more frequent “bad days,” but the insurer could still deny your claim.

You should follow your treating physician’s restrictions, even if you are having a particularly “good day” and believe you could do more than usual.  For example, do not shovel snow, lift heavy bags of groceries, mow the lawn, or rock climb.  And use any assistive devices (cane or walker) your treating physician ordered.

  1. Missed Deadlines

Missed deadlines are another reason for denied claims. If you receive disability insurance through your employer, than your plan is governed by ERISA, which provides you a limited window to appeal an initial denial (180 days) with the insurance company.  If you miss a deadline, you could waive your right to obtain benefits.  With respect to ERISA, if you fail to appeal with your insurer, you will not be able to sue in court since ERISA requires that you first exhaust “administrative appeals.”  Additionally, when you do file an administrative appeal, you must submit all of your supporting evidence because federal courts may only consider the evidence contained in the administrative file.  You cannot submit new evidence in court.

Consult a New Jersey Disability Insurance Lawyer

Increase your chances of a successful application or appeal for disability benefits by contacting the tenacious New Jersey disability insurance attorneys with Uscher, Quiat, Uscher & Russo, P.C. at 1-800-797-5575.

 

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