Common Reasons for Claim Denials

Why Am I Being Denied Benefits?

The attorney must undertake a detailed case analysis to develop a strategy for decision making and pre-empt the expected review which will be employed by the carrier. Many times clients have handled their own applications and appeals in a manner that is not effective against a comprehensive and aggressive claim reviewer. These houses of cards are knocked over with a feather. A good foundation and solid claims construction is necessary to withstand aggressive claims processing.

The following is a list, in no specific order, based on our law firm’s experience of the most often cited reasons for claim denials:

  • denial issued with no statement of the specific reasons for the denial
  • changing basis for denial; follow the bouncing ball
  • not disabled within the Elimination Period
  • onset of disability did not occur while policy was in force
  • “Not under the regular care of physician,” or wrong type of care-“not appropriate care” or “no in-person treatment”
  • no “objective evidence of disability”
  • “symptoms are merely self –reported” no objective evidence of the degree and frequency of the symptoms – OFTEN seen in MS cases
  • condition is amenable to treatment or claimant is not compliant or can work with treatment, medications etc…
  • no change in condition from when claimant was working with the impairment
  • prescription/pharmacy records “do not support amount of medication claimant reports taking” or “document that claimant averages X pills per day which would not cause symptoms alleged” or “do not document any changes in medications or dosages to support claimant’s alleged worsening of condition”
  • disable due to mental/ nervous and 24 month provision is invoked
  • not a true disability, but a personality trait not amenable to treatment
  • job not occupation; not disable from “own occupation” only disabled from job as they performed it
  • can do all the “material duties” of occupation or job
  • occupation “at time of disability” – claimant modified the occupation and kept working or just supervised and waited to file
  • claimant was “dually employed” as Y & Z and can perform Z; able to perform the material duties of occupation or job Z even though cannot perform Y
  • “misrepresentation by claimant” of income, job description or medical history or failure to disclose excessive disability coverage when clearly not the case
  • condition did not “first manifest” “while policy was in force”
  • failure to provide “timely notice” of claim as specified
  • review by their VE; can perform some material duties or dispute over the “material duties of job or occupation,” “what is job or occupation”
  • review by their experts who question severity of symptoms, claimant’s motivation, credibility or establish disability as of onset date that precludes benefits
  • IME or Peer Review or Peer to Peer phone call supported denial
  • nothing has changed; claimant worked previously with impairment and no change in condition is supported by objective medical evidence in record
  • denials based on PI surveillance denials, claimant was seen or recorded…; visit by field representatives to claimant’s home documented…; credit card charges showed frequent trips out of town (you can fly, you can work denial)
  • SS games: client not found disabled by SS; client’s SS decision states that most significant impairment is X and we only cover Z or coverage for X is limited to 24 months; non-examining, non-treating State Agency doctor agrees with assessment of insurance company; found disabled by SS but SS had different or incomplete information – not reliable determination.
  • ERISA applies
  • failure to exhaust administrative remedies
  • evidence not presented timely to plan administrator; not part of claim file prior to exhaustion of administrative process
  • application defective