Common Reasons Why Disability Claims Get Rejected

Paine Edmonds - Wednesday, October 10, 2018

No one wants to be injured to the point of being unable to do their job. Unfortunately, sometimes an illness or injury will prevent a person from being able to perform job duties, whether for a short or extended period of time.

If you have been injured and you are covered by an employer or personal disability plan, you may be concerned about your claim being rejected. Disability insurance policies can be confusing. In today’s blog, we explore some of the various reasons that a claim may be rejected and which of these reasons may be avoidable.

Incomplete Applications or Administrative Errors

Unfortunately, many claims are denied purely because of an error in the application or an error in the application process. The insurer may claim that you did not provide adequate supporting evidence of your disability. You may have missed a crucial document or a deadline.

Ineligible for Coverage

In order to have a successful claim, you need to be sure you are covered (e.g., that you qualify for your employer’s disability plan and that your payment of premiums for a private policy is in good standing). You also need to be certain that you meet the stipulations of the plan.

Disabilities with a short, finite duration may be covered by a short- term disability plan provided by your employer (or purchased privately), while illness or injury lasting greater than 6 months may be covered by a long-term disability plan. While it depends on the wording of the benefit plan or insurance policy in question, for continuance of benefits after the initial claim, most disability policies typically require that you be unable to substantially perform your “own occupation” for a period of time and then be unable to perform “any occupation.” Long-term disability policies often switch from “own” occupation to “any” occupation at a point in time, often after about two years.

Insufficient Evidence of Disability, or Severity of Disability

Understanding what evidence is required to substantiate a claim for disability can also be confusing. However, understanding what constitutes sufficient medical proof to make out a claim, and acquiring the necessary medical documentation to support these claims, can be difficult to navigate. Physicians’ and other health practitioners (occupational therapists, physiotherapists) notes and diagnostic reports must show the exact nature of your symptoms, and how they limit your ability to perform the tasks of your employment. An experienced disability lawyer can help you ensure that your claim submission meets the requirements and lessen the chance of denial the first time around.

Disability Excluded by the insurance Policy

In certain cases, disability policies may exclude certain types of illnesses and conditions, depending on what caused them, and will typically exclude pre-existing conditions. Again, consulting with a lawyer can help you understand whether your claim was justifiably denied, or whether he or she believes that the policy was unfairly interpreted against your favour. Often, the employees of the insurance company who determine whether to deny your claim are not lawyers and may simply not understand what legal arguments can be made to show that a claim ought not to have been denied. An experienced disability lawyer in Vancouver can advocate on your behalf.

For example, in a recent BC decision, the court awarded the plaintiff full indemnification, and all of her litigation costs, for long term disability benefits denied to her by her insurer. The defendant insurer had argued that the plaintiff’s inability to work was not caused by her worsening multiple sclerosis, but rather, as a result of illicit drug use. Although the plaintiff had used some illicit drugs (evidently, in an attempt to aid her symptoms), the court was unable to find, on the basis of all the evidence, including expert evidence, that this was the cause of the plaintiff’s disability.

Contradictory Surveillance or Evidence on Social Media

As may be obvious, insurers are not eager to pay out any more than they are required to and they wish to make sure that they are not paying out any claim that is fraudulent. Insurers will go to all necessary lengths to ensure that they are not paying out claims in vain and they will often go as far as to investigate claimant’ social media accounts (Facebook, Instagram, etc.). They will do so in order to see if any pictures or other evidence indicate a claimant is engaging in activities that cast doubt on their inability to work or that cast doubt on their credibility by contradicting any statements made by the claimant.

Unfortunately, snapshots from social media sites do not always give the full picture about a person’s experiences and they can unfairly sabotage a claimant seeking disability benefits. it is always wise to keep strong privacy settings on your social media accounts and to avoid posting too much about anything that might somehow misguide a judge about your health status.

Consult With Paine Edmonds LLP for Disability Benefits You Are Entitled

In order to ensure that your claim is handled expeditiously and to avoid inordinate delay, it is wise to consult with a disability lawyer in Vancouver who has experience with the process. At Paine Edmonds LLP, a disability lawyer will not only ensure that you do not prejudice your claim in any way, but also make certain that your claim is filed properly the first time around. Your lawyer will then serve as an advocate for you if needed to help you obtain the benefits for which you are entitled. You can contact us to schedule an appointment today or give us a call, toll free, at 1-800-669-8599.