Why Are Disability Claims Wrongfully Denied?

When you believe that you have a legitimate disability insurance claim, it can be quite shocking and scary to learn that it has been denied. What should have been a straightforward claims process that resulted in you receiving the financial support you needed has now become a stressful, long-lasting battle with piles of paperwork. 

While hundreds of thousands of people are approved every year, far fewer than half of those who apply have their claim initially approved. Often, they are denied for these reasons: 

Medical Evidence is Lacking

Support organizations like https://www.hercasematters.com/ regularly hear from women who have had their disability claim denied because medical evidence is lacking. In many situations, the reason cited is that the evidence is incomplete or poorly presented.

Insurance companies may reject a claim and request more information if doctors didn’t clearly document a patient’s functional limitations, or if medical records are missing, outdated, or inconsistent. 

It’s also common to be declined if the condition is hard to measure, such as mental illness, fatigue, or chronic pain. Essentially, they don’t want you just to prove that you’re sick; they want you to prove that you can’t work. 

Not Meeting the Technical Criteria

Every insurance provider has different acceptance criteria. Not neatly fulfilling their requirements can result in an automatic denial. The criteria are known to be quite strict. For example, qualifying for Social Security Disability Insurance (SSDI) requires you to have:

• A qualifying medical condition that meets the Social Security Administration’s disability standards
• Work history and credits from jobs that Social Security covers 

Many SSDI claims are denied because the condition isn’t severe enough, should improve, or doesn’t meet the legal definition of a disability. 

Human Error and Backlog Pressures

Decision-makers are often under immense time pressures to process claims. This can sometimes result in rushed decisions and overlooked documents. There’s also a risk of evidence misinterpretation. In these situations, disability insurance claims can be wrongly denied. What’s more, many decision-makers rely on summaries, rather than the full medical files, which further increases the risk of mistakes. 

Non-Treating or Consulting Doctors

Insurance companies want to ensure they’re approving or denying claims with medical accuracy, which is why they use consulting doctors, also known as medical directors. Using their medical experience and long-standing careers, they assist with underwriting, claims management, and the development of medical policy. They also review complex cases.

While their knowledge is invaluable, they aren’t a patient’s long-term treating physician. Therefore, they’ve never met the claimant and generally perform only a brief evaluation after a quick review of the records. This can result in denials that feel disconnected from reality. 

Not Following Procedural Steps

Sometimes, a claim denial can result from a claimant not following the required procedural steps. They may have missed the deadline, didn’t attend the required exams, or submitted incomplete forms. In this case, the denial isn’t about the disability, but it can still mean the disability claim is denied. 

Hearing that your disability claim has been denied can be stressful, especially when you believe it’s a legitimate claim. If yours has been rejected for any of these reasons or others, seek legal support to review your options as soon as possible. 

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