As you probably already know, navigating the disability insurance system in British Columbia can be difficult and stressful.
Having your disability claim denied can be devastating and leave you wondering where to turn next. Luckily, claimants can appeal a disability decision up to three times per claim. However, you only have so long to act and it can take up to 90 days to receive a decision regarding your appeal.
It is common to receive help with a long-term disability appeal from an experienced disability lawyer to increase your chances of success. The disability lawyers at Stephens & Holman are here to help you understand the appeals process and how to prepare an effective case.
Common Reasons for Denial
Claims can be denied for a variety of reasons. Disability insurance companies are required to outline why your claim was denied. If you’ve received a denial letter, you’ll want to review the reason(s) listed and the evidence the company provides to support their decision. Even if the reasons listed seem insurmountable right now, there may be an opportunity for a successful appeal.
Although there are many potential reasons both large and small for a claim denial, those most frequently listed fall into four broad categories.
Lack of medical documentation. It is common for insurance companies to state that the appropriate documents were not included. This can be a confusing reason for rejection because the company rarely states which documents are missing. There are standard documents a successful claim will always include but whether these are “sufficient” to support your claim is ultimately subjective. Experienced disability lawyers can help identify what’s missing.
The injury does not meet the requirements for “total disability.” The phrase “total disability” is used a lot by insurance companies but it doesn’t mean what you probably think it means. Firstly, it is not a legal term. It is a catch-all for claim reviewers who find it hard to dispute that you have a significant illness or injury but don’t want to approve your claim. So, they attempt to avoid paying benefits with the “total disability” language to argue that although you may be hurting, you’re not hurting enough for it to prevent you from working.
Your condition isn’t serious enough. This could be in reference to any injury, illness, or disorder that the insurance company views as not warranting benefits no matter its severity. These are usually the so-called “invisible diseases” like disorders of mental health or those difficult to test for medically such as fibromyalgia. These are typically rejected on the grounds that they aren’t the types of health issues that warrant benefits like a back injury or cancer might. But you know that isn’t true; invisible diseases can be just as debilitating as any other illness or injury.
Insurance company surveillance indicates your medical claims are inaccurate. It isn’t uncommon for insurance companies to surveil you. They may genuinely not believe your claims or simply want to undermine your disability application. Always follow the advice of your doctor. A lawyer can help you understand the implications of a doctor’s advice and provide guidance on how to avoid insurance company scrutiny.
If you don’t see your denial reason listed here, don’t panic. A lawyer can help you interpret your denial letter. Understanding the reasons for your denial is critical to mounting a successful appeal. Keep in mind that insurance companies aren’t required to list every reason your disability application might be rejected. There may be additional reasons for application rejection beyond those listed.
When to Appeal
It is your right to appeal a denial for any reason but some cases are more likely to succeed than others. If you’ve seen a new doctor (like a specialist) who supports your disability claim, or your current doctor is unaware that your condition has worsened, you’ll want to include this new information in an appeal. Claims that involve “invisible diseases” like PTSD or bipolar disorder might benefit from an expert perspective and additional information.
Also, if your initial application was missing a key piece of information and was denied on the grounds of insufficient medical documentation or even a minor mistake, you’ll almost certainly want to appeal. A lawyer can help you determine what’s missing and help acquire that information. They can also help avoid costly errors like incorrect dates or poorly organized applications.
Preparing Your Appeal
While we recommend working with an experienced disability lawyer to prepare your appeal, it is also very important that you understand the appeals process. You are at the heart of an appeal that includes your medical records, your physician’s statements, your statements, and perhaps testimony from friends, family, or your employer verifying any outward signs of your condition. A successful appeal is likely to include the following steps.
- Request your file from the disability insurance company. Insurance companies are required to provide you with your case files. A lawyer can help ensure they do so within a reasonable amount of time. Having the same information they do can help connect the dots regarding your claim denial.
- Obtain new and updated documents. A lawyer can help reach out to your medical providers to obtain all relevant medical records related to your disability claim. Your appeal should include the most recent and complete medical information. We can help determine whether a more detailed medical history will better support your claim. If you have new information to report to doctors, you’ll want to obtain any outstanding medical records after seeing them.
- Seek updated physician’s statements. Even if the physician on your case demonstrates a clear understanding of how your injury inhibits your day-to-day activities, they may not have done so in your medical records. Whether you’d like them to add new information or clarify old information, it isn’t uncommon to ask your doctor to be more specific or expand on the impact your injury or illness has on your ability to work.
- Respond to the reason for your denial. One of the most important aspects of an appeal is addressing the specific reason for your denial. Experienced disability lawyers know how to craft a persuasive claim that directly refutes the insurance company’s reasoning. Your appeal’s supporting details should support your counterargument.
- Add persuasive details that support the diagnosis and records. Focus on functionality instead of your diagnosis. Insurance company claim reviewers are unlikely to be experienced medical practitioners. It is therefore important when crafting your claim to connect the dots regarding your diagnosis to the physical and mental restrictions and limitations you experience in the workplace. For example, don’t just say “I have a broken arm.” Instead, outline how your broken arm affects your ability to lift, type, and operate machinery.
- Properly compose, format, and proofread your appeal document. It is very important to use simple, clear, and concise language. This can be difficult, as medical topics can be complex. Well-integrated personal details and descriptions of your supporting documents can help tell a compelling narrative about the obstacles you face and why you need benefits. While the focus of your appeal will be addressing the original reason for claim rejection, you should also anticipate any future reasons for an insurance company denial.