Have you suffered an injury at work or recently been diagnosed with a long-term disability? Is your insurer or the Quebec Pension Plan (QPP) denying your disability benefits claim? We know how stressful this can be, especially when you’re already suffering from a health condition. Luckily, there are steps you can take to appeal such decisions.
In this article, we explain everything you need to know about what to do when your long-term disability claims are denied. We explain the reasons why it might have been denied in the first place, and what you can do throughout the appeal process to ensure that you get the compensation benefits to which you are entitled.
What does it mean to be denied insurance?
If your insurance is denied, it means that your insurance provider has refused your claim and will not give you any money. WIth regard to healthcare and disability claims, you will receive a denial letter once your insurer has assessed your medical conditions.
Unfortunately, social security disability insurance claims for individuals with long term disabilities are denied 60% of the time. This means that even those who have a legitimate claim to long-term disability coverage are denied the insurance they need in order to live comfortably.
Why was my disability denied?
Despite the fact that many people rely on disability benefits due to their inability to work or provide for themselves, it is often the case that claims are denied by insurance providers. But on what grounds are these claims denied? Below are some of the most common reasons why insurance providers or QPP deny disability claims.
Insufficiently severe or prolonged condition
The most common reason disability claims are denied is because an individual’s health condition is not considered to be severe or prolonged. For a disability to be considered severe, you must demonstrate an inability to gain regular employment. Therefore, you need to be able to prove that you are unable to make a sustained living due to your condition.
It is important to remember that insurance companies and QPP use medical evidence given by your doctors as well as the medical reports you have submitted. Your doctors must clearly explain your condition and demonstrate to the assessor why your condition prevents you from working.
Without such explicit information, your insurer will assume that you are able to do some form of work and deny you insurance. A prolonged condition means that you have a long-term disability that cannot be cured. If your insurance provider deduces that you will recover from your disability in the near future, they will refuse your claim.
Age
Although unfair, this is one of the most common reasons why disability claims are denied. Your disability assessor will scrutinize your age and automatically assume that if you are younger, you are less likely to need compensation benefits.
Their flawed logic assumes that those under 40 have more opportunities to seek medical treatment to treat their condition. Moreover, they believe that younger individuals have more employment opportunities at their disposal and will, therefore, investigate whether you have explored every single possible avenue for employment, including work-from-home options.
Non-compliance with medical professionals
If you have been offered medical care that will improve your situation, and limit the extent to which your disability affects your everyday life, and you have refused to accept it, you will be denied disability insurance payouts.
A licensed physician will always be consulted on your case, and if they highlight treatment options that have been refused, your insurer will assume that you have done so in order to receive disability and employment insurance. They will deny your claims until you have undergone the treatment, and your abilities following the procedure have been re-assessed.
No official diagnosis
An official diagnosis is essential if you are applying for disability coverage through your insurance provider. Without an official diagnosis, you have no proof of a long-term or short-term disability, and your insurer will not take your word for it.
Unfortunately, it can be difficult to officially diagnose certain conditions. This makes it virtually impossible for your doctor to explain your inability to work. Without a doctor’s explanation of the condition from which you might be suffering, the compensation insurance coverage will be refused.
How does disability insurance work?
How long does it take to get disability approved?
On average, most insurers will aim to get your disability claim approved within 4 months, which is roughly 120 calendar days. Although your application will only be approved once you have sent in your fully completed application and your medical report, we suggest sending off your application form as soon as possible in order to get it processed, and your medical form as soon as you have it.
This will speed up the process. If you have a pre-existing condition that you have flagged as serious, your insurers will rush your application to the front of the queue, and you should get your approval within 20 days. For terminal conditions, your application could be approved within a matter of days.
What to do if I am denied coverage under a disability insurance policy?
If you are denied disability under your insurance policy, there is an appeal process that you can go through. Since such a large number of disability claims are denied every year, we recommend this step.
Consult a lawyer
The first thing you should do if your health insurance plan has refused your claim is to seek the advice of a lawyer. Claiming your disability benefits is stressful, and appealing a decision can be even more stressful. It helps to have someone in your corner who knows what they are doing. Consulting a disability lawyer who knows the ins and outs of long-term disability denial appeals will ensure that you have the best possible chance of gaining a ruling in your favor.
Act quickly
You need to kickstart the appeal process as soon as you get the letter of denial. The longer you put it off, the more time you will spend without weekly benefits, as well as without current employment. By delaying, you risk having no income for a prolonged period of time.
Moreover, most insurance companies have deadlines that prevent you from appealing a decision after a certain time period has elapsed. If you don’t act quickly, you are more likely to miss the deadline and won’t be able to secure your compensation.
Inform your employer
Your insurance company will inform your employer that they have denied your claim and that they believe that you are fit to work. You need to counter this claim and inform your employer that you are appealing this decision and won’t be able to return to work.
Depending on your workplace’s sick leave policy, informing your boss of your inability to work will likely be all you need to do to get the required time off. However, if your employer prefers to adopt a sterner outlook, you might need to contact your doctor in order to get a written letter clarifying your inability to work.
Put together your appeal letter
Once all the logistical elements are in place for your appeal process, you will need to get down to writing your appeal letter. In order to do this properly, you should first assess the denial letter in order to fully understand the reason for the denial.
You should then collate all the relevant documents you can that pertain to your disability period, including health plans, doctor notes, your medical history, and treatment records. With this evidence, you can write a compelling letter, detailing why the decision against your claim was wrong and why you are entitled to disability insurance.
Need a disability insurance lawyer?
Whether you are in the process of applying for your disability claim or appealing a decision by your insurance company, it is essential to have an insurance lawyer by your side who can talk you through the entire process. At Accident Solution, our professional insurance lawyers are trained to deal with all sorts of insurance inquiries.
We offer services for various categories of coverage, including:
- Disability insurance
- Life insurance
- Health insurance
- Liability insurance
- Professional liability insurance
- Damage insurance
- Loan insurance
- Annuity insurance
- Borrower insurance
- Death insurance
- Home insurance
- Home loan insurance
Following an initial consultation, our lawyers will work alongside you in order to ensure that you receive the compensation that you are entitled to. They will help you collate all the relevant evidence for your case and will recommend customized solutions that will help you obtain the outcome you want.
