Denial Reason #1: Mental Health issues not followed by a doctor
The insurance company says that you can do your job. They, however, don’t work in your environment every day. Some people go back to work and try their best to complete the daily demands of their work. This return to work effort may fail. If you can’t do your job and go off again the insurance company will reconsider your right to disability benefits. They are now assessing you as someone who originally went off work and then gave their job a second chance (that didn’t work). This step may demonstrate to the insurance company that your claim for benefits should be approved. Solution: If you are not going to a doctor now – find one. If you are seeing a doctor, be sure that you are speaking to him or her about the issues preventing you from working. Be sure to not miss appointments and that you carry through with all recommendations made. Be sure to book in a future appointment before leaving the doctor’s office.
Denial Reason #2: Not seeing a Psychiatrist for mental health concerns
Denials can come in many forms. Be sure that you know what you’re appealing by requesting that the insurance company lay out their grounds for short term disability denial in detail. Insist that the insurance company confirms what information they reviewed when making their decision. The steps for an appeal are generally provided in the denial letter. The obligation is usually on the applicant (you) to acquire new medical information for the insurance company’s review. The cost for acquiring new medical records and reports is yours to bear. In order to limit your cost and better the quality of your appeal, your documents should address the reasons for denial. Once your appeal documents are submitted the insurance company must reply with a decision. The decision will be to approve your claim or continue to deny your application. If the appeal is denied, move on to the next step (below). Solution: You can easily solve this problem by getting a referral from your doctor to a Psychiatrist. Of course, you need to be followed by a doctor in the first place to get this referral. There is often a long wait between your referral date and your first appointment. Be sure to call the Psychiatrist’s office and ask about appointment cancellations.
Denial Reason #3: Not following treatment recommendations
Don’t be surprised if your treatment includes a mixture of medication and psychological treatment. Some people are unwilling to take medication because of side effects, while others simply don’t want to be on any type of drug. While you are not obligated to take the medication, not following the recommended treatment plan will usually lead to a denial of your claim. The best way to avoid the medication stalemate with your treatment provider is to make them fully aware of your beliefs and preferences. There is little reason to object to counseling and non-medicine based treatment. In fact, any objection generally leads to prompt rejection of the claim. Beyond your willingness to attend, you must show up and actively participate. Missing appointments will flag your file for non-compliance. Notation in your file about your lack of effort will also be a mark against your claim. Solution: Just do it – and do it well. Unwillingness to follow treatment shows that you aren’t invested in your recovery potential. Be sure to try your absolute best and be ‘on’ when you have an appointment. You must be sure that the psychiatrist writes that you are trying your best and showing maximum effort.
Denial Reason #4: Being a good patient who followed bad medical advice
Solution: This is challenging for those without medical training. As a patient, you are not bound to see only one doctor. Get a second opinion if you believe you are receiving bad medical advice.
Denial Reason #5: No paperwork documenting mental health concerns
Always keep in mind that the insurance company is going to need hard evidence before it approves a claim for disability benefits claim. If it isn’t written down by the doctor or psychologist, it didn’t happen. The challenge we often hear from treatment providers is that they spend their limited time treating the patient, rather than completing paperwork. While the client’s doctor or psychologist may clearly express to you that you are disabled, they simply don’t put the time required to be equally as clear in their paperwork. This position is completely understandable but may be a point to raise with the treatment provider. If the treatment provider recognizes that you need the disability benefits, they may be more receptive to seeing the paperwork as a necessary step towards achieving the outcome. Your records must include the frequency of treatment, your attendance, quality of participation, diagnosis, and progress (or lack thereof). It is critical that the records are as accurate as possible. The medical record from the treatment provider will be scrutinized by the insurance company (and a medical consultant who practices in the same area) so accuracy is essential. Solution: Order the file from your treatment provider. You can also obtain the information from the insurance company. Be sure to review the documents and see whether there are any important aspects of the claim that appear to be missing. Oftentimes a list of follow-up items to the treatment provided can fill information gaps.
Denial Reason #6: Bad paperwork
Perhaps not as bad as no paperwork, bad paperwork can also be detrimental to a claim. Examples of bad paperwork can include: • sloppy treatment notes from a treating physician or psychologist • missing comments regarding diagnosis • no comment on your inability to complete job duties • not replying to questions posed by the insurance company assessing the claim Solution: You can always try to seek out a second opinion or transfer your case to a new doctor or therapist. You can also make a list of points for the treatment provider to consider. Your treatment provider may not be familiar with the inner workings of the disability claim process. A friendly reminder about the importance of your claim and the importance placed on fully completed and accurate medical documents may be all that is needed.
Final thoughts from Disability Lawyer- Jeff Mitchell
By avoiding the reasons for denial commonly experienced by disability benefits claimants you are well on your way to having your claim approved. Be sure to see your doctor as soon as possible and maintain regular appointments. Inquire about a referral to a psychiatrist at your next appointment. Be sure to explain the specifics of your injuries to your doctor. Take the time to also explain in detail why you are unable to complete the regular duties of your own occupation. While it may seem repetitive, the psychiatrist must also be told why you believe you are unable to work. The psychiatrist requires detailed information in order to create an appropriate treatment plan. An appropriate plan is one that you are comfortable with and one that is also medically appropriate. Keep in mind that you are not wedded to treatment from any one doctor or psychiatrist. You are able to seek out a second opinion about your case. Once a treatment plan is developed you must follow it to the best of your ability. You must be shown to be compliant and engaged in your care. The insurance company must see that you are making a good effort to get better and return to work. Some people will never return to work – but all of them have proven that they are unable to work, despite quality medical care. Even if you avoid the common pitfalls which lead to denied claims, your claim may be denied. Some denials are reasonable because your disability does not rise to the level of total disability. Other denials will be unfair. If you believe that your benefits have been unfairly denied, you should seek out legal advice right away. A disability lawyer will be able to provide you with options and a suggested path forward.
Jeff Mitchell is an experienced Long Term Disability Benefits Lawyer who has successfully advanced his client’s interests before the Nova Scotia Public Service Trust Fund. To book your free consultation, call toll-free: 1-855-670-1345 or 902-702-3452. Prefer to email? Email Jeff at [email protected].