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Disability Insurance: Appeals

Step 1. Find Out Why Your Claim Was Denied

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When an insurance company denies a claim for disability, it will send a letter which should give the reasons for the denial, although the reasons stated may be somewhat vague.

Make sure you understand the exact reason(s) why the claim was denied. Often the denial letter is not specific -- it will say something like "lack of medical documentation."

If you have any questions, call the claims person and discuss it - in as friendly a manner as possible. Consider acting confused, not angry. Once you know the general area, you can ask follow-up questions to determine specifics to help you determine what you need to do. Following are some common reasons why claims are turned down, and what to ask:

  • Missing or incomplete medical records about your medical condition.
    • Which records were used? For what dates?
    • If medical records are missing, what is missing?
      • Is the company missing your therapist's records when mental issues were a major part of your symptoms?
      • Did the records fail to include some lab tests or an outside specialist's comments?
      • Did your doctor use only a word or two to describe your symptoms or fail to include some symptoms in the notes?
  • It's not clear whether you were able to perform work described in the plan.
    • What occupation did the insurer use?
    • What job description did the insurance company use?
      • In general, was the description accurate and complete? Did the insurer think you were a classroom teacher when you only taught one class but were also the wrestling coach?
      • Did the insurer's description of what is done in the job reflect your job, or just a generic version of your job? Sometimes, the employer pulls out a pre-printed description that is so generic it could fit every employee - and not describe your job at all. Sometimes, the insurance company will switch from your actual occupation to the one in their occupational guidebook (every claims office uses one) and judge your disability on the job that is spelled out in the book - even if it's wrong.
  • Was there insufficient proof about your symptoms?
    • It is particularly difficult to prove symptoms that cause your inability to work when they are largely subjective.
    • Pain and fatigue are two symptoms that are particularly hard to use in support of a claim.
  • Is there a claim that there was no coverage?
    • If the company maintains that there is no coverage, find out which policy provision they are relying on to deny your claim.

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