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5 Common Reasons Why Disability Insurers Deny Claims

Fri Jul 31st, 2020 on     Insurance Law,    

Experienced Insurance Law Firm in Miami, FL

If you’ve submitted a claim for disability benefits in Florida and have had your claim denied (or if you are planning on submitting a claim for benefits), then you may be feeling confused and overwhelmed.  In truth, policyholders are not powerless — so long as they understand the strategies that the insurer is likely to employ.

Let’s take a look at some of the common reasons for a disability claim denial.

Insurer Believes That You Can Still Work

Definitions of “disability” vary from plan-to-plan.  Generally, a policyholder will be considered disabled if they cannot perform the primary responsibilities of a job.

Some plans have a narrower construction of “disability,” requiring that you show that you cannot perform the primary responsibilities of any-occupation.  In other words, you must prove that you cannot do any sort of work for which you’re reasonably qualified.

Other plans have a broader construction of “disability,” requiring that you show that you cannot perform the primary responsibilities of your own-occupation.  In other words, you must prove that you cannot continue to work in your chosen career path.

Failure to Follow-Through on Medical Care

As a disabled policyholder, it’s critical that you follow-through with medical care, and that you do so in a timely manner.  Failure to do so could lead to a denial of your claim for benefits, and such denial would likely be upheld by a Florida court.

How does this justification work?

Suppose that you are injured in a car accident.  You fracture a bone in your leg, but instead of going to the hospital, you decide to go home and “wait it out” for a few days.  You finally go into the hospital for treatment two days later.  The doctors discover that your leg is infected (because of the delay), and though you do receive treatment, there are long-term physical issues due to the condition having been exacerbated by infection.

Under these circumstances, the insurer may argue that you are not entitled to benefits whatsoever, or perhaps, that you are entitled to a significantly lower payout.

Failure to Disclose Related, Pre-Existing Condition

Policyholders who fail to disclose “material facts” in their disability insurance application, particularly with respect to pre-existing conditions, are likely to have their application for benefits denied.

For example, suppose that you are attempting to make a claim for benefits for a neck injury that causes 24/7 stiffness and pain.  What you did not disclose on your disability insurance application, however, was that you were already suffering from a degenerative spinal cord disease impacting your neck region.  This later developed into the stiffness and pain symptoms that you’re now experiencing.

Under these circumstances, the insurer could reasonably argue that these facts are material to insurance coverage, and that your failure to disclose such facts prevents you from recovering benefits under the plan.

Diagnostic Evidence is Disputed

Oftentimes, the disability insurer simply disagrees with your medical professionals, and will utilize their own team of medical professionals.  These professionals will examine your medical records and potentially arrive at a different diagnostic conclusion.  If there is ambiguity, you need not accept the insurer’s interpretation — it’s possible to challenge their conclusion, and if they stick by it, then to pursue litigation and introduce additional medical expert testimony in your favor.

For example, at trial, you could introduce the testimony of vocational experts who have clients with similar medical records (and diagnosis), and whose clients are unable to perform the responsibilities of their job due to the physical limitations.  This sort of testimony would provide significant support for your disability insurance claim.

Surveillance Reveals Inconsistencies in Physical Limitations

Traditionally, insurers would hire investigators to “follow” disability claimants in public and take photos/video to catch the claimant performing physical tasks that reveal inconsistencies with regard to their purported limitations.

For example, if you claim that you can’t work because your back injury prevents you from bending down and picking things up — and then the investigator takes photos of you playing recreational football on the weekend with friends — it’s likely that this inconsistency will be used to counter your disability claim.

The use of surveillance footage has become increasingly common thanks to social media and other online profiles.  The proliferation of personal information online has made it rather difficult for policyholders to keep their life “private” and away from the prying eyes of insurance investigators.  For this reason, it’s worth consulting with an experienced attorney (and their network of experts) for guidance on what you can do to avoid undermining your own disability claims.

Of course, if the insurance investigator has discovered an inconsistency, it does not necessarily spell doom for your benefits claim — you could argue that the limitation is not absolute, but only prevents you from functioning for a longer period of time (i.e., several hours, which would be necessary for work).

Contact VPM Law for Assistance

Here at Ver Ploeg & Marino, P.A., our team of attorneys has decades of experience working with disability insurance policyholders, helping them to secure the benefits that they’re owed under their coverage plans.  We are committed to providing truly personalized advocacy, and to that end, we engage closely with our clients from beginning-to-end — this allows us deep insight into their claim and gives us an advantage when positioning them for negotiations and potential litigation.

We believe that legal representation in the disability insurance context must be comprehensive in nature.  Over the years, we have developed a trusted network of experts and disability professionals who can provide supportive testimony and other services to strengthen your claim for benefits.

If you’d like to speak to a qualified attorney at our Miami insurance law firm, contact us today to request a consultation.  We look forward to assisting you.

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