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