Common Reasons Disability Claims are Denied

You have been paying into your company group benefits plan for years. You have been a hard worker, giving your best to the company. All of a sudden disaster strikes. You develop an illness that saps all your strength and leaves you struggling to get out of bed in the morning. You get into a car accident that causes severe neck, shoulder and upper back pain that simply won’t go away despite months of physiotherapy or chiropractic treatment. You fill out the disability claim forms and have your doctor complete medical forms confirming that you are not capable of working. Yet, you get a telephone call from the insurance company saying that your claim was denied.

Here are some of the common reasons the insurance company will deny a claim:

No Objective Evidence

Insurance companies routinely deny disability claims due to a lack of “objective evidence”.  Certain types of illnesses, such as migraines, fibromyalgia and chronic fatigue syndrome, cannot be definitively proven by x-rays, MRI’s or other diagnostic tests.  What the insurance company refuses to understand is that there is no “pain machine” or “fatigue tester” that will measure how hurt you are or how tired you become. However, Fibromyalgia, chronic fatigue syndrome and chronic pain are legitimate medical conditions that have been recognized by the medical community and by courts of law.

Pre-Existing Condition

Most disability policies contain clauses that exclude payment of benefits for any pre-existing medical conditions.  A disability is deemed to be pre-existing when the claimant suffers from the medical condition before becoming insured under the policy. Group disability insurance policies (placed through employment) will usually only exclude a pre-existing condition if an employee becomes disabled within one year after they become insured.

Policy Exclusions

Every long-term disability policy will contain a list of exclusions. For example, an insurance company will not pay a benefit for any disability caused by an intentional self-inflicted injury. Neither will a benefit be paid if the disability occurs as a result of a commission of a crime or illegal act. A disability policy may also exclude disabilities that result from participation in a riot, war, or a disability arising out of the use of drugs or alcohol.

Contractual Eligibility

The majority of group long-term disability policies contain technical eligibility requirements. There may be a waiting period for which a person must be employed before being eligible for coverage. Most group policies also have “active employment” clauses which require an employee to be working a minimum number of hours before being eligible for benefits.

Misrepresentation on the Application

Individuals who wish to purchase a personal disability insurance policy will normally complete a full application, including a health questionnaire. If someone fails to disclose important medical information, the insurance company may deny any subsequent disability claim and void the policy on the grounds of material misrepresentation.

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Regardless of the reason that a disability claim is denied by an insurance company, it is important to speak to a disability lawyer about your case. The insurance company’s decision is not necessarily the final word – a court of law may strongly disagree with the insurance company’s denial of benefits.

Contact Mark Yazdani today for a free and confidential discussion about your case.  Mark can advise you of your legal rights and can commence a lawsuit against the insurance company for the recovery of benefits.

416-630-8880     1-877-311-8880


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