Insurance Claim Denied? Why Insurance Companies Deny Most Claims

Posted on August 29, 2018 by cjblog

You’re probably wondering how the insurance company could have possibly denied your disability insurance claim. Unfortunately, it is very common to be denied on the first try. Insurance companies are not in the business of paying out every claim that comes their way. But understanding why and how they deny claims can help you develop the best case you can when you appeal.

If you have a denied claim, you have options. As ERISA disability attorneys, our team at CJ Henry Law Firm has helped many of our clients appeal unfair denials and collect the evidence they need to prove their case. In cases where the insurance company was acting in bad faith, we can help you dispute the decision in court. You don’t have to simply accept a denied claim and give up. Call us today to see how we can help.

Reasons Insurance Companies Use to Deny Claims

Insurance companies deny claims for all types of reasons, but not always legitimate reasons. The real reason, however, is that they want to force you to prove just about any claim you make. In the event that you can prove your claim, they will eventually honor your claim (usually). If you want your claim to be honored you will need to leave no doubt that you are unable to work.

"Insufficient Medical Evidence"

The long-term disability insurance provider will expect that you can provide sufficient evidence that you are unable to work. This includes showing that treatment options have not proven to be successful and are unlikely to be successful. You must further prove that your disability prohibits you from doing your job. Some policies will stipulate that your disability prevents you from working entirely.

A long term disability benefits attorney can help you contact doctors and ask for the proper evidence. This includes ordering medical tests. In some cases, we will bring vocational experts on board who can assess your capacity to work your current job or any job at all.

By doing so, we have won a number of appeals for our clients.

"Failure to Meet Policy’s Definition of the Word What a Disability Is”

This can be a little tricky. Depending on the exact wording of your policy, your situation may not qualify as a disability. Some policies will define “disability” as the inability to perform the tasks of your current job. Other policies will define disability as an inability to perform the tasks of any job. Some policies set a two-year clock on the inability to perform the tasks of your current job that automatically defaults to the second definition after those two years have run out.

So, depending on how your policy defines the word “disability”, you may or may not be entitled to collect on the policy given your situation, medical issues, and job requirements. A disability lawyer can help you review your policy's summary plan description to see whether you meet the definition of disabled.

"Evidence Is Inconsistent With Your Claims"

If you are making a claim for long-term disability benefits, you can expect you will be under investigation. The insurance company is looking for any reason to deny your claim. This is especially true if it’s a large claim for a longer period of time.

This may include using their internal private investigators to conduct surveillance on you. Insurance companies have denied many fraudulent claims using these techniques. If the insurance company can find a contrary medical opinion or video surveillance that refutes your claims, you can bet that it will not be honored.

Sometimes, the insurance company will use video surveillance records to justify a denial, even if the recording doesn't necessarily prove that you are not disabled. For example, let's say you have a condition like fibromyalgia, where you may have "good days" with less pain and "bad days" with more pain. If there is video of you gardening or doing other light housework on your "good days", the insurer can use this to justify their denial of your claim.

"Evidence for Your Claim Is Subjective"

Conditions like depression or fibromyalgia are difficult to prove. Depression is difficult to prove because there is no way to test for it other than to ask the patient. Fibromyalgia has the same problem and the diagnosis of it is based on a patient reporting where their pain is. In a case where the evidence for your claim is based on your own firsthand account, the insurance company will likely deny your claim. It then becomes a matter of finding doctors who will testify on your behalf.

Insurance Claim Denied: Talk to a Ocala Florida Disability Lawyer

If your insurance claim is denied, you can file an appeal with the help of an experienced attorney. CJ Henry Law Firm has helped several clients just like yourself win claims against insurance companies. Don’t fight the insurance company alone. Call us today.

This entry was posted in Blog by cjblog.