Why Disability Insurance Claims Get Denied
When you need disability benefits most, a claim denial can feel like a punch to the gut. You paid your premiums, you followed the rules, and now you’re stuck without the income you were counting on. Understanding why insurance companies reject claims can help you avoid common pitfalls and strengthen your case if you need to appeal.
Our friends at The Law Office of Bennett M. Cohen discuss these issues regularly with clients who thought their claims were airtight. If you’re dealing with a denial, a disability benefits lawyer can review your case and help you understand your options.
Insufficient Medical Evidence
This is the number one reason claims get rejected. Insurance companies want detailed documentation that proves you cannot work. A simple note from your doctor saying you’re disabled usually won’t cut it. They want diagnostic test results, treatment records, specialist evaluations, and detailed reports about how your condition affects your daily activities and work capacity. Many people assume their doctor will automatically provide everything needed. That’s not always the case. Your physician might not understand what the insurance company requires, or they might not document your limitations thoroughly enough.
Missing Deadlines
Insurance policies have strict time limits for filing claims and submitting additional information. Miss a deadline by even one day, and your claim could be denied outright. These deadlines often appear in the fine print of your policy, and insurance companies rarely send friendly reminders. Common deadline issues include:
- Filing the initial claim too late after disability begins
- Not submitting the requested medical records within the specified timeframe
- Missing appeal deadlines after a denial
- Failing to provide updated medical information during the review process
Pre-Existing Condition Exclusions
Many disability policies include exclusions for conditions that existed before your coverage started. Insurance companies dig through your medical history looking for any mention of symptoms or diagnoses that relate to your current disability. If they find something, they may argue your condition was pre-existing and therefore not covered. The definition of “pre-existing” varies by policy. Some policies only look back a few months, while others examine several years of medical history.
Your Occupation Doesn’t Match Policy Terms
Disability policies define disability differently. Some cover you if you cannot perform your specific occupation (own occupation coverage). Others only pay if you cannot work in any occupation for which you’re reasonably qualified (any occupation coverage). If you have an “any occupation” policy, the insurance company might deny your claim by arguing you could still work in a different field, even if it pays far less than your current job. They sometimes hire vocational experts to identify other jobs they claim you could perform.
Lack of Ongoing Treatment
Insurance companies expect you to follow your doctor’s treatment recommendations. If you stop seeing doctors, miss appointments, or refuse recommended treatments, they may deny your claim. They argue that if you’re not actively seeking treatment, you must not be that disabled. This creates problems for people who cannot afford expensive treatments or who have tried everything without improvement. Gaps in treatment, even with legitimate explanations, can hurt your claim.
Surveillance and Social Media
Yes, insurance companies investigate claimants. They hire private investigators to follow people and record their activities. They also scour social media looking for posts or photos that contradict your claimed limitations. A photo of you at a family gathering might be used to argue you’re not really disabled, even if you were in pain the entire time.
Incomplete or Inconsistent Information
Small inconsistencies in your application, medical records, or statements can trigger a denial. If you describe your limitations differently to different doctors, or if your activity level seems to vary significantly, insurance companies will use that against you.
What You Can Do After a Denial
Most denials can be appealed. Review your denial letter carefully to understand the specific reasons given. Gather additional medical evidence, get detailed reports from your doctors, and consider getting an independent medical evaluation. Many policies have short appeal windows, so act quickly. Don’t try to handle a complex denial on your own. Insurance companies have teams of lawyers and doctors working to minimize payouts. Getting legal help can significantly improve your chances of winning an appeal and securing the benefits you deserve.