A denial of your short-term disability claim doesn't have to be the final word. You have the right to appeal, but the process requires careful attention to deadlines and procedures.
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Being denied short-term disability benefits—whether through your employer, a private policy, or a state program—takes away an important financial lifeline you need when you can’t work due to an off-the-job injury or illness. (On-the-job injuries or illnesses are generally covered through workers' compensation insurance.)
You have the right to appeal a short-term disability denial, but it's important to act quickly. The appeal process is time-sensitive, and you must follow the insurer’s appeals process. Skipping steps or missing deadlines could cost you the benefits you need.
Short-term disability claims can be denied for many reasons, including mistakes that can be corrected, like a missing document or unanswered question. So understanding why your claim was denied is the first step toward winning your appeal. Knowing how the appeals process works and the kind of evidence you need to get a denial reversed can improve your chances of getting the benefits you need.
This article explains the most common reasons for short-term disability denials, the steps involved in filing an appeal—including what kind of evidence you’ll need—and when you might want professional help with your case.
7 Common Reasons Short-Term Disability Can Be Denied
Short-term disability policy terms and benefits can vary widely, depending on the type of policy you have. For instance, an individual policy you purchase directly from an insurance company might have more restrictions than a group policy (like one your employer might provide). And state-mandated short-term disability plans (like those in California and New York, for example) often have the fewest restrictions. Whether you got your short-term disability insurance through your state, employer, or on the open market, it's important to read the terms carefully.
There are a lot of reasons insurance companies deny short-term disability claims. Some of the most common include:
1. Your Condition Isn't Covered by Your Short-Term Disability Policy
Most short-term disability policies cover most non-work-related injuries and illnesses. But there are some exceptions. For instance, some group policies cover mental health issues (like anxiety), but many personal policies don't.
2. Your Short-Term Disability Claim Involves a Pre-Existing Condition
Under the Affordable Care Act, most group health insurance policies can no longer exclude pre-existing conditions. But both short-term disability and long-term disability insurance policies can. And most policies won't pay benefits for disabilities due to any condition you've received medical treatment for in the 12 months before your claim. (Some short-term disability policies treat pregnancy as a pre-existing condition for up to the first year you have the policy.)
3. You're Not Actively Working When You Become Injured or Sick
Your short-term disability should cover you when you're not working because it's a weekend or holiday, or when you're on vacation. But there are times—like during a leave of absence or if you're between jobs—when your disability claim might not be covered, even if you're still paying the premiums. Read the fine print.
4. You Failed to Provide Adequate Proof of Your Disability
When you file a claim for short-term disability benefits, the insurance company will need to see convincing proof that you're unable to work because of a specific injury or illness. The claims adjuster will look for tests (like X-rays) that show measurable restrictions. If your disability is caused by a condition that's hard to document with medical testing (like depression or fibromyalgia), it can be more difficult to prove your claim.
5. You Took Too Long to Submit Your Claim or Made a Paperwork Mistake
Most policies set a strict time limit to submit your claim (which can vary from 30 days to 12 months after your injury or illness caused you to miss work). If your claim form is incomplete, contains errors, or is submitted late, it can cause your short-term disability claim to be denied.
6. You Weren't Disabled Long Enough
Most short-term disability policies have an "elimination period" or "waiting period" (a minimum length of time you must be unable to work) before you're eligible for benefits. Elimination periods of 7 to 14 days are common, but the wait time can be longer.
7. The Insurance Company Doesn't Believe You're Disabled
The insurance adjuster will look for signs that your condition doesn't really prevent you from working. If you're doing things in public that you claim you can't do (like standing for long periods or lifting heavy items), your short-term disability claim could be denied.
And be careful of posting pictures on social media. If you post pictures of yourself doing anything you claim you can't do because of your disability, your claim could be denied.
How to Fight a Short-Term Disability Denial
If your short-term disability claim is denied, the insurance company or the claims administrator must notify you in writing. The notice will usually include specific instructions regarding deadlines and the steps you need to take to file your short-term disability appeal. Once you've received that written denial notice, you have the right to appeal.
A short-term disability appeal is your formal request for the insurance company to reconsider its decision, typically supported by additional or corrected evidence.
Step One: Learn the Rules and Deadlines for Appealing Your Short-Term Disability Denial
As soon as you learn your claim's been denied, find out how and when you must file an appeal. The insurance company might have included this information along with the letter denying your claim. But if you don’t receive these details with your denial letter, contact the company immediately and ask it to provide information on filing an appeal.
The deadline for filing a short-term disability appeal will vary from policy to policy, but for ERISA-governed plans, it's 180 days; other programs and policies may use a 60-day deadline. If you miss the deadline, you'll likely lose your right to contest the decision—even if your short-term disability made it difficult to get things together in time.
Step Two: Find Out Why Your Short-Term Disability Claim Was Denied
The denial letter should give the insurance company's reason(s) for denying your short-term disability claim. If it doesn't, contact the company right away and request this information. If the company claims that you didn't follow the proper procedures or submit the right paperwork for filing a claim, review your claim form to see whether the company is correct. Then gather any paperwork or information you're missing.
Step Three: Collect Evidence to Support Your Short-Term Disability Claim
Make sure the insurance company isn't missing any of your medical records. Ask the claims examiner what records were used to decide your short-term disability claim. If it seems like any documents are missing, let the claims representative know. And ask if additional objective testing (like X-rays, MRIs, or blood tests) would help your case.
Depending on why the company denied your claim, you might also want to gather the following:
- additional documentation from your doctor
- a second medical opinion
- written observations by coworkers or others about your injury or illness, and
- any other written proof that you're entitled to short-term disability benefits. (For example, if you were injured in a car accident, you might want to submit the police report and written records from the emergency room staff who treated you.)
Step Four: Submit Your Short-Term Disability Appeal
Follow the insurance company's rules to the letter when filing your appeal. You might have to write a statement explaining why you believe you're entitled to short-term disability benefits. You might need to:
- resubmit your original claim
- file another report from your doctor, or
- provide other information.
Make sure you follow all the insurance company's procedures so that your short-term disability appeal won't be denied on a technicality.
Getting Help Appealing a Short-Term Disability Denial
If you need help preparing your appeal, consider talking to a long-term disability attorney (many also handle short-term claims). An attorney can help you assess your situation and determine what you need to do to win short-term disability benefits on appeal. Your lawyer can also help you assemble all the necessary evidence for your appeal.
Even if your short-term disability claim is denied, you could still have the right to take unpaid, job-protected leave under the Family and Medical Leave Act (FMLA).
