What to do if your disability insurance company refuses to pay a claim?

If your insurer refuse to pay your claim, or pays too little, your first step, as the insured, is to immediately review the policy, plan or evidence of coverage document relating to claim or benefit denial, appeal or grievance procedures.

Most often, there is a requirement that the insured appeal a denial of a benefit or service with a written appeal within a period as short as 15 to 60 days. In addition, there are typically multiple levels of appeal or grievance, which are mandatory and which involve subsequent short time limits. Appeal or grievance procedures, depending on the policy or plan, either require that final determinations of entitlement to benefits or services be made by required arbitration, or they allow the insured or member to file a lawsuit, but only after exhausting the appeal or grievance procedures set forth in the policy or plan.

While legal assistance from an attorney is not necessarily required at the initial levels of appeal, it is strongly urged as soon as possible if the amount involved is large, or the insurer is denying that you are “disabled” under the terms of the contract or the matter is going to arbitration or lawsuit. Rest assured that the insurer or plan will almost certainly be represented by an attorney, and s/he or he will be out to have your claim denied.

Case Studies: Disability Insurance Claim Denials and Resolutions

Case Study 1: John’s Denied Disability Claim

John, a 42-year-old software engineer, suffered a serious injury that left him unable to work temporarily. He filed a disability insurance claim to help cover his medical expenses and lost income. However, his insurance company denied his claim, stating that his injury didn’t meet their definition of disability. Frustrated and unsure of what to do, John sought legal advice.

Case Study 2: Mary’s Underpaid Disability Claim

Mary, a 55-year-old business owner, experienced a sudden health issue that forced her to stop working for an extended period. She had disability insurance coverage, but when she received the benefit payout, it was significantly lower than what she expected. The insurance company cited policy limitations as the reason for the reduced payment. Feeling cheated, Mary decided to take action.

Case Study 3: Tom’s Uphill Battle in Appeals

Tom, a 35-year-old teacher, had a long-term disability insurance policy that he relied on after an accident left him unable to teach. When he filed his claim, the insurer rejected it, asserting that his condition was a pre-existing one not covered by the policy. Tom was adamant that his condition was unrelated to any pre-existing medical history, and he decided to pursue an appeal.

Case Study 4: Jane’s Legal Victory

Jane, a 50-year-old sales representative, was in a car accident that resulted in severe injuries, making her unable to work. Her disability insurance company denied her claim, arguing that her injuries were not substantial enough to hinder her from performing her job. Determined to fight for her rights, Jane sought the assistance of an attorney to challenge the denial.