8 Reasons Social Security Disability Can Be Denied

January 29, 2024

Navigating the process of applying for short-term disability benefits can be fraught with complexities. Understanding the common pitfalls that lead to the denial of claims is critical for those seeking this essential financial support. Short-term disability insurance serves as a lifeline for many individuals who, due to illness or injury, find themselves unable to work for limited periods. However, a substantial number of these claims are denied for various reasons.

The criteria for short-term disability benefits are stringent, and insurers meticulously review each application to confirm its validity. Insufficient medical evidence is one of the primary obstacles applicants face. It is incumbent upon the claimant to provide comprehensive documentation that substantiates their inability to work. Additionally, failing to meet the policy’s eligibility requirements can result in denial. Matching the insurer’s definition of disability, avoiding any implication of fraud, and correctly navigating exclusion periods are all vital steps in the approval process.

Discrepancies in the information provided or overlooking details about pre-existing conditions frequently lead to denial. Claimants must present a well-documented case that aligns with their policy’s terms. With the right preparation and understanding of the common grounds for denial, individuals are better equipped to navigate the process and increase the likelihood of securing their benefits.

Eligibility Criteria Not Met

When pursuing short-term disability benefits, it is critical for claimants to meet specific eligibility criteria. Failing to satisfy these requirements is a principal reason for benefit denial.

#1 Insufficient Work History

Short-term disability policies typically necessitate a minimum period of employment before a worker qualifies for benefits. If an individual has not worked with the employer for the required amount of time, their claim may be denied on the grounds of an insufficient work history.

• Minimum Employment Duration: Often a specific number of months or years
• Recent Work Requirement: Certain policies demand recent and continuous employment leading up to the disability

#2 Lack of Qualifying Disability

Not all medical conditions meet the insurers’ definition of a disability. A qualifying disability usually requires evidence of an inability to perform work duties.

• Medical Evidence: Documentation proving the severity of the condition
• Policy Definitions: The condition must align with the policy’s definition of disability. If a claimant’s condition does not impede work to the extent required by their policy, the claim could be denied.
• Application Issues: When applying for short-term disability benefits, applicants must navigate two critical pitfalls: incomplete application forms and documentation errors. Each aspect is scrutinized by insurers to ensure all necessary details are provided correctly.

#3 Incomplete Forms

An insurer can deny a claim if the application form is not fully completed. Vital information, such as personal details, employment history, and the nature of the disability, must be accurately filled out. Applicants should double-check their forms for any blank fields that could result in a denial.

• Personal Information: Name, address, Social Security number.
• Employment Details: Job title, length of employment, salary.
• Disability Information: Diagnosis, prognosis, treatment plans.

#4 Documentation Errors

Proper documentation is essential, but errors within these documents can lead to a claim being denied. This includes inconsistencies in the diagnosis reported by different medical providers or discrepancies between the claimed disability and the medical evidence presented.

• Incorrect dates or mismatched information.
• Insufficient medical evidence to support the claim.
• Signatures missing on required documents or forms.
• Policy Limitations: When evaluating short-term disability claims, insurance companies meticulously review policy terms. Two critical provisions that often lead to claim denials are the presence of a pre-existing condition exclusion and unsatisfied waiting periods.

#5 Pre-existing Condition Exclusion

Short-term disability policies frequently include specific provisions regarding pre-existing conditions which can preclude coverage. A pre-existing condition is a health issue that existed before the coverage start date. Claims related to such conditions are often denied if they manifest within a defined period after the policy begins, commonly known as the “look-back period.”

#6 Benefit Waiting Period Not Satisfied

Every short-term disability policy has an established benefit waiting period, also referred to as the elimination period. This is the time between the onset of a disabling condition and when benefits can begin. If a claimant files for benefits before this period is fully satisfied, the claim is likely to be denied. The waiting period is intended to ensure that the disability is not fleeting and requires the stipulated duration to validate the claim.

Employee Conduct

When assessing short-term disability claims, insurers scrutinize employee conduct, particularly looking for instances of non-compliance with medical treatment or fraudulent activities.

#7 Disability Eligibility Criteria

To qualify for short-term disability benefits, it’s important to note that a person doesn’t necessarily have to be disabled for a full year. However, the disability must be expected to last at least a year or more to meet eligibility criteria. This means that if a person’s medical condition is expected to improve within a shorter period, they may not qualify. For instance, even if someone has been disabled for only a few months, they may still be eligible if the condition is anticipated to last beyond a year. It’s the duration of the expected disability, rather than the actual time they’ve been disabled, that plays a crucial role in determining whether short-term disability benefits are granted.

#8 Non-Compliance With Treatment

Insurers require claimants to adhere to prescribed medical treatments to qualify for benefits. If an employee fails to follow a treatment plan recommended by their healthcare provider without a justifiable reason, this can lead to the denial of their short-term disability claim. Documented evidence of treatment adherence is often a pivotal factor in the insurer’s decision-making process.

#9 Fraudulent Claims

An insurer will deny a claim if there is evidence of deception. This includes any attempt to obtain benefits through the intentional provision of incorrect information regarding the disability, or the fabrication of a medical condition. Investigations might involve checking the consistency of the claimant’s statements, reviewing medical records, or even surveillance to confirm the severity of the claimed disability. If fraud is suspected, the insurer has grounds to deny the claim outright.

How a Lawyer Can Help if Short-Term Disability Is Denied

Navigating the complexity of short-term disability insurance can be daunting, especially when a claim is denied. Short-term disability insurance provides a safety net for individuals unable to work because of a medical condition, but the process of securing these benefits is often fraught with intricate legalities and stipulations. When a claim is rejected, it can lead to financial strain and uncertainty, leaving many to wonder about their next steps.

This is where the expertise of a disability lawyer becomes invaluable. A skilled attorney from Pisegna & Zimmerman will examine the reasons for denial, determine the best course of action, and represent the claimant’s interests effectively. With strict timelines and procedural requirements in place, especially under laws such as the Employee Retirement Income Security Act (ERISA), it is crucial to act promptly and with knowledgeable guidance. A Pisegna & Zimmerman lawyer’s involvement may mean the difference between a successful appeal and prolonged hardship.