Why was my claim 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 for years. 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. Yes, you get a telephone call from an insurance adjudicator saying that your claim was denied.

Insurance companies deny claims for many reasons. One of the most common is that there is no objective evidence for disability. What they mean is that there is no x-ray, MRI, CT Scan or other type of medical documents that clearly proves the presence of a legitimate medical condition. What the insurance company refuses to understand is that conditions such as pain and fatigue do not show up in medical diagnostic tests. There is no “pain machine” or “fatigue tester” that will track how hurt you are or how tired you become. Conditions such as fibromyalgia, chronic fatigue syndrome, chronic pain syndrome, and myofascial are legitimate medical conditions that have been recognized by the medical community. However, insurance companies will routinely deny claims involving these conditions on the basis that they cannot be proven by medical tests.

Insurance companies will also routinely deny claims on the following grounds:

  • They have surveillance which they say proves a person is capable of working
  • The medical forms submitted by the claimant’s doctor are not detailed enough
  • The claimant has not received regular medical treatment for their condition
  • The claimant’s medical condition constitutes a pre-existing disability that is excluded from payment
  • The insurance companies believes that the disability is caused by workplace issues as opposed to a medical issue
  • The insurance company doctor (who has not assessed you) believes that the medical condition is not severe enough to prevent the person from working

Regardless of the excuse provided by the insurance company for denying your claim, it is important to not to give up. Consult with a Toronto disability lawyer to determine whether the insurance company can be challenged in court for denying your claim.