Why Are Disability Claims Denied?
Many disability claims are based on mental illnesses which generate an inability to work. Unfortunately, depression, anxiety, or other mental illnesses are often trivialized or considered insignificant by insurance companies. In fact, the insurance company’s treatment of the claim may even worsen symptoms and further prevent many workers from completing their jobs.
In our experience, insurance companies are less likely to approve claims for depression, anxiety or mental illness compared than for physical injuries. The truth is that a high number of the cases we see relate to mental illness (rather than physical harm), yet the insurance system isn’t well equipped to properly evaluate the claims.
No worker should be denied just because their claim is more complex than a physical injury disability claim. Usually, a more complex claim is a signal that the worker is unable to work! Atlantic Canadians often consult a disability lawyer for assistance with their disability claim. While the entry points vary, the theme is clear: help is needed to convince the insurance company that anxiety, depression or another mental illness is preventing the person from completing the usual duties of their occupation.
The purpose of this article is to help you better understand the reasons why insurance companies deny non-physical injury claims for disability benefits. Knowing why the insurance company denied your claim puts you in a better position to advance your claim without making mistakes which may prolong the denial and prevent the decision from being overturned.
Given the prevalence of disability claim denials for mental illness, it is only natural to be concerned that the insurance company may change their position and refuse to pay future benefits.
How does the insurance company assess my mental health disability claim?
Let’s begin with an overview of the industry. Disability insurance providers allow workers to make claims for compensation if the workplace duties cannot be completed. There are many reasons why a worker’s duties can’t be completed, but they generally fall into two categories:
- Physical injuries prevent completion of work duties
- Mental health related injuries prevent completion of work duties
Of the categories above, mental health injuries are often less visible, harder to fix, and increasingly common. Mental health claims are concerning for insurers who seek to minimize payment for disability claims, which then allows them to stay competitive and profitable by offering lower premiums to their happy customers. The insurance industry has given themselves a helping hand by re-writing their policies to limit the types of claims which will be honoured. Some companies have even gone so far as banning disability claims stemming from mental health issues. Beyond policy exclusions, the companies have taken an aggressive approach to adjudicating mental health related disability claims. The policies and procedures developed by many companies make the benefits process very difficult. Many are left frustrated and exhausted in their quest to prove their claim to the insurance company.
If you can get your claim approved, you will often find that there is a treatment plan in place which will limit the compensation ultimately payable. You may be sent to an “independent” medical consultant for assessment and be found to be okay, or that you only struggle due to workplace-related issues (bad supervisor, toxic work environment, funding cutbacks, concern about layoffs, etc.) rather than a treatable medical condition.
The thread which ties mental health and physical injury disability claims together is the phrase “treatable medical condition.” If you do not suffer from a medical condition, you will not have a claim. In fact, the condition must not only be treatable, but in the process of being treated or managed. In most policies, there is a requirement that you are under the care of a medical practitioner.
Finally, a word about medical professionals. It is sometimes the case that medical professionals provide one set of conclusions to the patient while another set of findings is written in the medical chart. Doctors may take this approach because they feel explaining the medical terminology isn’t helpful, or they may wish to ‘cushion the blow’ by telling you a slightly different version. In other cases, you may have misread what your doctor said. It may be the case that the insurance company was correct to deny your claim based on what is written in your medical records. Given the importance of your medical files, it is essential that you get that information from your doctor and review it yourself. There are other times, however, that your doctor misunderstood the circumstances surrounding your inability to work. If the doctor knew more about your inability to work, perhaps he or she might support your inability to work. It is important to keep in mind that your medical professional will make conclusions about your health (diagnosis) and recovery potential (prognosis), but those aren’t often tailored to your work environment! The disability claim process is different than the process undertaken by the medical practitioner.
While the specifics of disability policies vary, the common theme is the same: Does the worker have medical issues (physical or mental health) that prevent them from completing their job duties?
Do you want to talk about your options? Contact Jeff Mitchell to arrange for a free case review.