kotak: 4 roadblocks you may face when you file a disability claim

to challenge a denial, you need evidence showing the reason for the denial isn’t valid or that there’s information that hasn’t been considered in the assessment of the claim.

by nainesh kotak

published dec 15, 2022

3 minute read

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3 minute read

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kotak: tips to handle the denial of a disability insurance claim

the process may not be easy, but you have a legal right to contest a disability insurer’s decision. getty

in the past, risks of disability tended to be physical, from industrial accidents or injuries. but in today’s knowledge-based economy, mental health now takes up the majority of disability risk. in fact, according to sun life, overall disability claims rose 17 per cent from 2016 to 2019, driven mostly by mental health and chronic illness. but whether your disability is related to a physical issue or mental health, if you can’t work, it can cause a lot of anxiety to learn that your insurance company has denied your benefits claim — or cut you off from the benefits you were receiving.

a termination of benefits can be successfully challenged

the process may not be easy — especially as insurance policies are complex and filled with complicated legal language — but you do have a legal right to contest a disability insurer’s decision. but to effectively challenge a denial, you need evidence showing that the reason for the denial isn’t valid or that there’s information that hasn’t been considered in the assessment of the claim. it also helps to be aware of the common roadblocks faced by claimants when dealing with disability insurers.

denials based on a pre-existing condition. insurance policies often contain a pre-existing condition clause that disqualifies the applicant from receiving benefits if the coverage was in effect for less than a year before the disability arose. the insurance company investigates the 90-day period before the policy took effect to determine if you have been treated for or taken any medication directly or indirectly related to the condition associated with the claim.

for example, let’s say you file a claim related to anxiety, but the insurance company’s investigation reveals you were previously treated for depression. because mental health ailments such as depression and anxiety are commonly combined, your claim will be denied based on a pre-existing condition.

case managers with a hard-line attitude. case managers often treat legitimate claims with suspicion, and once they make a decision, it’s difficult to change their position, even when new information is provided. we often hear from clients that their case managers don’t believe them and make them jump through hoops to supply more and more information for their claim. for some, the constant phone calls and emails are so stressful that their mental health declines even more.

but if a lawsuit is submitted for a claim that was denied, the case goes to the insurance company’s lawyer who looks at the case in a much different light than the case manager does. it’s also important to be aware that insurance companies have to consider the cost of fighting a lawsuit and possibly losing in court — often, settling is the best option for everyone.

biased medical reports. insurance companies retain independent medical examiners, who frequently decide that claimants are able to work — despite the fact that they have never met or examined them. in many cases, these medical consultants haven’t even received the complete record of medical evidence from all the treating professionals, so their determination is based on limited and incomplete information. the best way to counter a biased medical examiner opinion is by providing solid evidence from medical experts, including from the professionals directly involved in treatment.

insufficient medical evidence. disability claims are often denied on the basis of insufficient medical evidence, which means the insurance company isn’t satisfied that the applicant has provided proof that they can’t work. disability insurers typically invite claimants to provide additional medical reports, but that often leads to a catch-22 situation: no matter what information you provide, you’re repeatedly told that the medical evidence remains insufficient and that you should get more information from your doctor at your own cost.

there’s no doubt that dealing with one or more of these roadblocks is both frustrating and stressful, but being educated on your rights and the options that are available should your claim be denied or discontinued and seeking the help of a disability lawyer can go a long way to ensure a successful outcome.

nainesh kotak, is the founder of kotak personal injury law, a firm focusing on protecting their client’s rights to justice and obtaining the compensation their clients deserve. he also serves as the chair of the long-term disability section of the ontario trial lawyers’ association.

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