Reasons Short-Term Disability Can be Denied

Short-term disability insurance is designed to provide temporary financial support to individuals who are unable to work due to illness or injury. However, there are several reasons why a claim for short-term disability may be denied. Below is a detailed list of common reasons for denial and explanations for each:

1. Insufficient Medical Documentation

One of the most common reasons for denial is insufficient or inadequate medical documentation. Insurance companies require proof that your illness or injury prevents you from performing your job duties. If your healthcare provider does not provide clear, thorough, and up-to-date documentation, your claim could be denied.

• Incomplete medical records: Missing information on diagnosis, treatment, and expected recovery time.
• Lack of support from a doctor: If your physician does not agree with the necessity for time off or fails to support your claim, the insurer may reject it.

2. Pre-existing Conditions

If your disability stems from a pre-existing condition, your claim may be denied. Most short-term disability policies have a pre-existing condition clause that limits or excludes coverage for conditions that existed before the policy’s start date.

• Diagnosis prior to policy: If you had symptoms or received treatment for the condition within a specific period before obtaining the insurance (usually 6 to 12 months), it may be considered pre-existing.
• Continuous treatment: If you were already receiving care for the condition before applying for disability benefits, it could be used as a reason for denial.

3. Failure to Follow the Treatment Plan

Insurance companies often require that you actively follow prescribed treatment plans in order to remain eligible for disability benefits. If you fail to adhere to medical advice, take medications, or attend recommended therapies, your claim might be denied.

• Non-compliance with doctor’s orders: Skipping appointments, missing medication doses, or failing to undergo recommended treatments could lead to a denial.
• Lack of improvement: If you do not show reasonable progress in recovery or fail to follow rehabilitation protocols, the insurer might argue that you are not genuinely disabled.

4. Not Meeting the Definition of Disability

Each short-term disability policy has its own definition of what constitutes a disability. If your condition doesn’t meet the insurer’s definition, your claim could be denied.

• Own occupation vs. any occupation: If the policy defines disability as the inability to perform your specific job (“own occupation”) but you can perform a different job, your claim may be rejected.
• Partial vs. total disability: Some policies only cover full, total disability, so if you’re able to work in a reduced capacity, even if not your usual role, the insurance might not approve your claim.

5. Missing the Claim Filing Deadline

All short-term disability policies have a filing deadline. If you fail to file your claim within the specified timeframe after becoming disabled, your claim can be denied.

• Late submission: Typically, the claim should be filed within a few days or weeks of the onset of the disability, depending on the policy. Missing this deadline could automatically disqualify your claim.
• Failure to inform the employer: If you don’t notify your employer within the time frame specified in your policy, the insurance company may deny the claim.

6. Engaging in Risky or Unapproved Activities

If the disability results from an activity not covered by the policy, your claim may be denied. This includes high-risk activities or actions that are excluded in your specific short-term disability plan.

• Injuries from hazardous activities: Injuries from activities like extreme sports, certain physical hobbies, or illegal activities may not be covered.
• Work-related accidents: If the disability arises from an accident that is covered under workers’ compensation instead of short-term disability, your claim may be denied.

7. Discrepancies Between Your Doctor and the Insurance Company

Insurance companies may have their own medical examiners or hire independent doctors to review your case. If there are discrepancies between your healthcare provider’s assessment and the insurance company’s evaluation, your claim could be denied.

• Contradictory opinions: If the insurer’s doctors believe you are capable of returning to work, even if your own doctor disagrees, this can lead to a denial.
• Questionable evidence: The insurer may challenge the validity of your medical records or the credibility of your healthcare provider, especially if there are inconsistencies or gaps in the documentation.

8. No Objective Evidence of the Condition

Some disability claims are denied because the condition is subjective and cannot be clearly substantiated with medical evidence. This is common in cases involving mental health conditions or chronic pain.

• Lack of diagnostic tests: Conditions like depression, anxiety, and chronic fatigue syndrome often don’t have clear, objective diagnostic tests, making it harder to prove that the condition prevents work.
• No clear clinical evidence: Conditions like fibromyalgia or migraines, which are often diagnosed based on patient history and self-reporting, can be hard to prove definitively.

9. Returning to Work Too Soon

If you return to work or begin performing work duties before your short-term disability benefits are over, it can result in a denial of your claim. Insurers often track return-to-work dates and may stop payments or deny benefits if you resume work prematurely.

• Resuming light duties: If you begin working at a reduced capacity, such as part-time or performing modified tasks, the insurer might consider you able to work full-time.
• Voluntary return to work: If you decide to return to work despite still being physically or mentally unable, the insurer may deny your claim.

10. Employment Status Issues

Short-term disability insurance is typically provided through an employer, and your eligibility for benefits is often tied to your employment status. If your employment ends, or if you are classified as an independent contractor or part-time worker, you may not qualify for benefits.

• Job termination: If you’re fired or laid off while on disability, or if your job status changes, your benefits may stop.
• Independent contractor status: Workers who are not full-time employees may not be eligible for short-term disability, depending on the policy.

11. Not Meeting the Waiting Period

Short-term disability policies typically include a waiting period, which is a set number of days that you must be off work before you start receiving benefits. If you don’t meet the requirements for the waiting period, your claim may be denied.

• Failure to meet the waiting period: Some policies require you to be out of work for a certain number of days (often 7 to 14) before benefits kick in.
• Unpaid sick leave: If you are on sick leave and not officially taking short-term disability, the insurer may deny the claim because the waiting period hasn’t been met.

12. Coverage Limits Reached

Finally, many short-term disability policies have a benefit period—a limit to how long you can receive payments. If you have reached your coverage limit or if the insurer determines that you’ve recovered enough to return to work, they may deny continued payments.

• Expiration of benefit period: Once the term of coverage has ended, you will no longer receive benefits.
• Improvement in condition: If the insurer determines that your medical condition has improved sufficiently for you to return to work, they may terminate benefits.

While short-term disability insurance is intended to provide essential financial support during times of illness or injury, it is not always guaranteed. Understanding the potential reasons for a denial and addressing them proactively can help you avoid disappointment. Keep in mind that medical documentation, timely filing, and understanding your policy’s exclusions are crucial to improving your chances of a successful claim.

If your claim is denied, it’s important to appeal the decision, gather additional medical evidence, and seek legal advice if needed.