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Short-term disability insurance is meant to cover at least part of a person's paycheck when they are unable to work because of an injury. Since some people may receive significant compensation, the insurance company could try and find ways to deny them coverage.
What can a person do after they receive a denial letter from the insurance company informing them they won't be covered? The short answer is that this person would have to file an appeal, and the best way to do that is to hire an experienced disability lawyer to help with the process.
Filing an Appeal or Accepting the Denial
When disability claims are denied, workers really only have two routes they can take. Their first option is to file an appeal in hopes of being able to obtain the disability benefits. The other one is to accept the ruling and not receive those benefits.
Sometimes, companies will act in good faith and provide some benefit to the employees who had their short-term disability claim denied. The problem for some workers is that time is not on their side if they're looking to receive a benefit from their short-term disability claims.
Both the insurance company and the companies that these people work for know this. Some denial letters will feature a poor excuse with the hope that the employee will accept the ruling to avoid the hassle of going through the appeals process.
Why the Claim Was Denied in the First Place
Here are a couple of reasons why a short-term disability claim can be denied. Once that happens, workers can decide to go through the aforementioned appeals process.
Preparing well for this process will determine whether a person can take down the insurance company or will have to contend with being unable to work or collect the insurance benefits.
Common Reasons for Short-Term Disability Denials
After receiving a short-term disability denial letter, the best thing that a person can do is read the letter carefully. It has to provide the reason why the insurance company feels that not granting the benefits specified in the policy is fair. These are some of the common reasons why a short-term disability claim can be denied.
Not Enough Time as a Company Employee
Most of these insurance policies are provided to the employee by the company they work for. In those cases, there may be a clause in the policy that states that the employee must work at that company for a set time period before being eligible. This clause can also hurt workers who are only working part-time.
Sometimes, it's the limited number of work hours per week with that company that disqualifies a person from the coverage.
How To Appeal This Claim Denial
This may be one of the hardest claim denial scenarios to appeal. Depending on the injury, though, the person could apply for long-term disability benefits. If the accident happened during working hours, they may be able to build a negligence case against their employer.
Insufficient Medical Evidence
When filing the original claim for short-term disability benefits, it's very important to collect as much medical evidence as possible.
The problem most people face is that they feel the injury obviously qualifies for disability benefits due to its severity. There's a sad truth in all of this: the insurance company doesn't want to pay these claims.
Therefore, the company is likely going to find something wrong with the claim file to get out of paying the rightful benefits. The only silver lining for people who've had this type of disability claim denied is that if the injury is severe enough, it's easier to win the appeal process.
Appealing This Claim Denial
Any disability lawyer who's presented with a case like this will want to collect evidence as quickly as they can, particularly if they're able to find new evidence that was present in the original claim.
This short-term disability appeal will have to prove that the injury is severe enough and the person who sustained it is entitled to short-term disability benefits.
Part of the process to collect evidence can include visiting another medical professional for a second opinion. There's always a chance that the insurance company and the doctor that they have people see are running a bit of a scam. Any additional evidence verified by a medical professional can really help these cases.
Pre-Existing Conditions
Short-term disability denials over pre-existing conditions are incredibly common. The insurance company will say that the condition was hidden from them when the person first bought the policy.
There's another common way that pre-existing conditions are used as the excuse for a denial letter, and this method is a bit more cruel.
Suppose that a person is at work, takes a hard fall, and breaks their ankle. Naturally, they'll want to file a short-term disability claim because they won't be able to work until the injury heals. The insurance company may claim in their denial letter that the fact that this person was overweight contributed to the development of the injury.
That's a preexisting condition, and therefore, the denial is "justified." It's important to point out again that what was just described is an entirely hypothetical situation. However, some insurance companies have tried to argue similar cases in the past.
The point here is that there can be unfair denial situations that involve this pre-existing conditions clause. In many of these cases, the insurance company won't necessarily argue that there was a disease that caused the issue. They could push for a pre-existing conditions denial in some odd circumstances.
Filing an Appeal in this Situation
Medical evidence and any additional evidence that could apply to a case like this will be the basis of the appeal. Going back to the broken ankle example, a good appeal will have medical evidence to prove that the person's weight was not the determining factor that led to the injury.
If, in that situation, there was a faulty or broken ladder that could've caused the fall, that's great additional evidence to build a case.
Sometimes, short-term disability benefits are not the only thing that a person would be entitled to receive. They could potentially file some type of negligence lawsuit against their employer as well.
The Injury Doesn't Qualify as a Disability
There is usually a set of injuries that the insurance company will designate as ones that qualify for short-term disability benefits. When the injury that a person sustains doesn't appear on the list, the claim can easily be denied.
Another reason why a disability claim is denied that falls along these same lines is because the insurance company believes the person is faking their injury.
If the claim is denied, the person can still prove that the injury is severe enough to qualify.
Filing an Appeal to Reverse These Claims
On many of these appeals, the best defense may be evidence that while the injury is not as severe, it does keep the person from doing their job. Therefore, they should be able to receive the short-term benefits they're entitled to.
Here's another hypothetical situation to help explain this specific appeal process. Suppose a worker suffers a broken finger. The insurance company sends them a denial letter because they deem the injury not serious enough.
What the worker can claim is that the broken finger is not a major disability, but it does prevent them from performing their job as a driver. Therefore, their short-term disability claim should be valid.
Situations Where Filing an Appeal May Not Make Sense
Good lawyers should be able to advise their clients when a fight isn't worth the trouble. What may be frustrating for some people in these situations is that the insurance company's decision is, in fact, wrong. All of the parties involved acknowledge it, yet the claimant is likely going to leave empty-handed.
That can be a tough pill to swallow, but it may be the best way forward. In some of these cases, it's better to fight for the right type of medical treatment that will allow workers to return to their posts and not miss out on more paychecks.
The Waiting Period is Too Short
There's typically a waiting period that has to pass for a short-term disability claim to come through. This was mentioned earlier; companies know this and will, therefore, send out a bit of bogus denial.
As mentioned, the insurance company denies these claims, hoping that the claimant feels the benefits are too low to go through the hassle.
It's important to keep in mind that most of these short-term disability benefits total only a fraction of the person's salary. Missing half a paycheck can put many workers in a tough situation. Sadly, going through the appeal process may be more of a hassle than it's worth, even in these situations.
It's Better to File for Long-Term Disability Benefits
If the short-term disability claim is denied, can the person still file a long-term disability claim? Yes, in fact, in some cases, it makes sense to appeal and file a long-term disability claim. It's important to speak to a workers comp attorney from Larrimer & Larrimer to figure out what the best course of action might be.
It could seem impossible to have long-term disability benefits approved after the short-term disability claims were denied. With fresh medical records that can prove the insurance company was in the wrong, workers can see their fortunes completely change, though.
The Company is Asking the Employee Not to Appeal
When a company asks one of its employees not to appeal the insurance company's decision, that person should seek legal advice immediately. This is a really tough spot to be in, and that's why it's posed as a question of whether or not it makes sense to appeal in this type of situation.
In an ideal world, a situation like this should lead the employee to seek legal action against their employer and the insurance company.
The reason why a company may take the risk of making this request is that it doesn't want the insurance company to increase its rates on disability insurance policies.
The employee is unfortunately backed up into a corner in these situations. They likely fear that they'll lose their job if they don't comply, but they're losing the benefits if they don't appeal. That's why the best thing anyone can do in this situation is seek legal advice.
What Happens If an Appeal is Denied?
There are still legal avenues that people who've had their appeal denied can explore. In most cases, that's going to involve filing a federal lawsuit against the insurance company that's denying the benefits.
If a person gets their appeal denied, they would do well to collect even more evidence, looking through medical records to see what they can find. Larrimer & Larrimer can also give insight on what happens to your workers' comp case if you die.
Why Are Appeals Denied?
Each case is unique; however, there are common reasons why appeals tend to be denied. Filing the appeal on time and in the proper manner is necessary to get it to pass. In some cases, the court may find that there is insufficient evidence to support this person's claims.
Perhaps what's comforting about the appeals process is that it takes place within the neutral legal system. When insurance companies have the power to fully determine if the benefits are going to be paid or not, it can put injured workers in a very desperate situation where they'll be almost completely powerless.
Final Thoughts
Receiving that denial letter from an insurance company can be a tough situation to be in. It signals that there's a process that lies ahead to be able to obtain the benefits that the worker wants to get without a hassle. Anyone in this situation should not panic and instead seek legal counsel quickly. They can also advise on changing doctors in your workers compensation case.
Unfortunately, many short-term disability denials are sent by insurance companies that are betting the worker won't be willing to go through with the appeal process. It's not that all insurance companies make approving a claim impossible. Sadly, in some cases, denials have increased.
It's important for workers to understand their coverages under these insurance policies. They must also have a sense of what their rights are. That way, if they find themselves in these situations, they can act fast to claim the benefits that they are entitled to.