Published on: January 19, 2024
When an illness or other type of medical condition prevents you from working, short-term disability benefits can replace lost wages. Unless you work in a state with a short-term disability program, your source for temporary wage-replacement benefits would be an insurance policy you purchase or a policy provided by an employer.
The fact that you have access to short-term disability benefits does not automatically guarantee the payment of benefits. This blog removes the uncertainty by explaining the top 10 reasons short-term disability can be denied.
Reason #1: Lack of Sufficient Medical Evidence Supporting the Claim.
Your good word may be enough for many things, but qualifying for short-term disability benefits is not one of them. Insurance companies and plan administrators require complete medical records that include the following:
- Physical examination notes and your physician's findings, including a diagnosis, treatment plan, and prognosis, including the condition's expected duration.
- Blood work and other laboratory testing results.
- Diagnostic imaging such as MRIs, CT scans, and X-rays.
The medical evidence should document a consistent and ongoing course of treatment for the condition that you claim prevents you from working.
Reason #2: Failing to Disclose a Pre-existing Condition.
Short-term disability plans and insurers generally deny claims based on medical conditions you had that predate the start of coverage. Short-term disability plans and insurance policies typically contain a clause excluding pre-existing conditions and ask you to disclose any known medical conditions.
Disability plans and insurers usually discover the existence of a pre-existing condition from a review of the medical records when you file a claim. A doctor’s notes from examining you or reviewing test results or your medical history may reveal that you aggravated a previous condition, which could be the basis for denying a claim.
Reason #3: Condition not Covered by the Plan or Policy.
Government programs and short-term disability insurance policies can exclude coverage for specific types of medical conditions provided the exclusion. For example, an insurance company can exclude mental health conditions from coverage under a short-term disability policy if it discloses the exclusion in its terms and conditions.
Reason #4: You are not Disabled.
Government programs and insurance policies clearly define what qualifies as a disability and refuse to pay claims that do not meet the definition. For example, an insurance company may deny a claim because a person is not disabled because they can do some of their job activities. If it happens to you, ask a disability advocate at Disability Experts of Florida to review your disability insurance policy to determine if the position taken by the insurer accurately reflects the definition contained in the policy.
Reason #5: You Provided Inconsistent or Inaccurate Information About the Claim.
Insurance companies carefully investigate and monitor claims for disability benefits to find inconsistencies and inaccuracies to use to deny a claim. For example, photos of a claimant participating in sports and other physical activities posted on social media may conflict with the information furnished by the claimant.
Reason #6: Failing to Follow a Course of Treatment Prescribed by Your Health Care Provider.
When a physician or other health care provider prescribes medication, physical therapy, or other course of treatment for your medical condition, you must follow it or risk a denial of the claim for short-term disability benefits. The reasoning is that failing to follow your doctor's instructions prevents you from recovering and returning to work.
Reason #7: Claims Arising From an Illness or Injury Related to Your Work.
An injury or illness caused by an accident or conditions at your job generally does not qualify for short-term disability benefits. Your source of benefits for work-related medical conditions is workers’ compensation.
Reason #8: Failing to Cooperate With The Short-Term Disability Provider.
You must cooperate with the insurance company, employer, or government agency that provides short-term disability benefits or risk losing them. For example, it’s common for insurance companies or employer-sponsored plans to ask for an independent medical examination by a physician they select to verify the findings of your treating doctor. You may lose your benefits by failing to attend the examination or unreasonably delaying it.
Reason #9: A Waiting Period Shorter Than the Time Away From Work.
Whether you are covered by an insurance policy, a government program, or an employer-sponsored plan, you probably have a waiting period before you can receive benefits. Waiting periods vary and affect the cost of the policy. You pay less for a policy with an extended waiting period than one that pays benefits sooner because you cannot receive benefits until the wait period ends.
Reason #10: Missing a Deadline for Filing a Claim.
Your insurance policy, employer-sponsored plan, or government program want claims filed promptly. If you have a medical condition that prevents you from working, file a claim for short-term disability benefits right away to avoid missing a deadline.
Get Assistance From Disability Experts.
When you need assistance with disability benefit claims, contact the professionals at Disability Experts of Florida. If you had a claim for benefits denied, let them review the claim and appeal to overturn the denial.