Common Insurer Justifications for the Denial of Private Disability Benefits

Oct 4, 2018 | Blog |

If you are suffering from a disability and have had your benefits claim denied by your private disability insurer, then you may be entitled to bring an action against your insurer — whether your insurance coverage was purchased individually or provided as part of an employer-sponsored plan.

Insurers are often quite aggressive in denying private disability benefits. In many cases, the insurer understands that if they deny a “difficult” or “ambiguous” benefits claim for which they can provide a reasonable justification, a number of claimants will simply refrain from any further attempts to secure their rightful benefits. This strategy saves insurers a substantial amount, as they can avoid having to payout benefits that they might otherwise have to pay if the claimant were to challenge the denial.

Consider the following justifications commonly used by private disability insurers to deny benefits.

Application of a Coverage Exclusion

Private disability insurance policies can vary drastically, and as such, your coverage may feature a number of exclusions that are unique to that particular insurance contract. Insurers may apply those exclusions in an over-broad manner to avoid having to payout benefits. It’s important that you seek the assistance of an attorney to evaluate the policy and determine the contours of those exclusions.

Some coverage exclusions are so common that they are nearly ubiquitous in the disability insurance context. For example, the vast majority of disability plans feature a coverage exclusion that makes those who intentionally cause their own disabling condition/injury ineligible for benefits.

Claim Submission Lacked Sufficient Information

When you submit your claim for benefits, it must include sufficient documentary evidence and information to support your claim — in fact, it must be so comprehensive that the insurer cannot reasonably deny your claim for insufficiency. If you are missing certain medical records in your application for benefits, for example, then the insurer is likely to use that as a basis to deny your claim.

Coverage Rescinded Due to Material Misrepresentation

Insurers often deny claims when they determine that the policyholder has made a material misrepresentation on the original application to purchase coverage. Insurers tend to be overly aggressive in enforcing this rule, however, and in doing so, they may unjustifiably rescind coverage (and deny your claim) without property considering whether the misrepresentation at-issue was actually “material” — in other words, relevant — to the coverage.

For example, if you misspelled your name on the insurance application form, that would be considered irrelevant to your coverage. The insurer could not use something so minor and immaterial to justify denial.

Disability is Related to a Pre-Existing Condition

When an insurer provides disability coverage, they generally exclude benefits for pre-existing conditions. Of course, insurers tend to be rather excessive in interpreting the extent of your pre-existing condition and the relatedness of your new disability.

Medical Treatment and Mitigation Concerns

Insurers will almost certainly deny benefits if there are significant gaps in your medical care after you have received an injury, or suffered an illness or condition that later causes you to become disabled. Most disability policies require the appropriate treatment of your medical condition. Policyholders must make reasonable efforts to seek and maintain appropriate medical care.

Contact a Skilled Chicago Private Disability Attorney for Help

Here at Bryant Legal Group, P.C., our attorneys have extensive experience representing private disability claimants in disputes with their insurance carriers, including situations that involve wrongful denials.  We understand the underlying dynamic that fuels the conflict between insurer and policyholder — the incentive to deny disability claims and thereby avoid having to payout benefits — and how to approach the dispute so as to secure maximum benefits on our client’s behalf.

Interested in learning more about your claims?

Call (312) 561-3010 today to schedule a consultation with an experienced Chicago private disability attorney at Bryant Legal Group, P.C.  We will evaluate your claims and help you to develop an effective forward-strategy.

Bryant Legal Group - Chicago Healthcare and Disability Attorneys


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