Who Decides What Counts As A Disability?

December 8, 2020 | J. Price McNamara
Who Decides What Counts As A Disability?

When you're sick or injured and can't work, you shouldn't have to wonder what counts as a disability. Your policy or plan summary should explain this in clear language. The wording should be clear and simple enough for you to understand your rights. Unfortunately, that's not always the case. When you enroll in an employer-sponsored, plan presenters often simplify key concepts. An agent selling a personal plan usually focuses on promotional promises, catchphrases, and closing the sale. Insurance agents and company plan administrators aren't around when a claim person makes a coverage decision. Insurers evaluate your personal situation and review the actual coverage. They don't consider any promises other than what's written in your policy. When the claim department makes a decision about your claim, only a few things matter.

  • Was the coverage in force when you became disabled?
  • What type of sickness or condition do you have?
  • Does your policy exclude your illness or condition?
  • Do you have medical proof of your disability?
  • What counts as a disability under your policy terms?

You Expect Your Disability Insurance Company to Pay

When you're disabled, you expect your insurance company to honor your disability claim. You don't anticipate a claim denial. Unfortunately, claim denials happen more frequently than they should. The Employee Retirement Income Security Act regulates employer-sponsored disability coverage. Despite government monitoring, long-term disability lawsuits make up 64.5% of ERISA-related coverage disputes. It seems unthinkable, but these numbers suggest that, instead of simply paying valid claims, some insurers might actively look for ways to deny them. That's unacceptable. If it happened to you, an ERISA lawyer can help you fight back.

Why Insurance Companies Deny Disability Claims

A disability insurance company doesn't always see things from your point of view. When you turn in a claim, they investigate every detail. When they ask key coverage questions, they don't always accept what you tell them. If they doubt your claim's validity, they verify the facts independently to answer these key questions.

Was your coverage in force when you became disabled?

This qualification seems easy enough. If you sustained an injury after you obtained disability coverage, the insurance company should cover your claim. Insurers look at it differently. If your doctor says you injured your back on a certain day, their doctor can find evidence to the contrary. They sometimes blame a disability on a pre-existing condition or say that your initial injury occurred before your coverage inception date.

What type of sickness or condition do you have?

If you have a job-related back injury that you believe is covered by your policy, the insurance company may decide otherwise. Until it passes their coverage analyses, your back injury doesn't qualify for coverage. Back injuries don't always involve fractures or tissue tears, or other visible signs an independent doctor can verify. Each back injury heals differently, so naturally, some people heal faster and more completely than others. Because back injuries sometimes involve subjective symptoms only, insurers feel comfortable taking the position that you don't have a back injury at all. If they agree you have a back injury, they might decide it's a longstanding condition. They can also decide that your back injury isn't disabling enough to qualify for disability benefits.

Does your policy exclude your illness or condition?

Policy exclusions are often simple but broad enough to exclude a range of conditions. They are also subject to a claim representative's interpretation. When a claim examiner decides that your sickness, circumstances, or job isn't covered, denying your claim becomes a simple formality. Policies include other provisions that eliminate or restrict coverage. If you have certain government-sanctioned benefits, they often reduce or eliminate employer-sponsored disability benefits. Policies also include waiting periods, employment eligibility requirements, and definitions that effectively prevent you from receiving payments.

Do you have medical proof of your disability?

When your attending physician tells you that you're disabled, that should be enough. Sometimes, insurers don't accept your doctor's diagnosis, so they schedule an independent medical examination.

What counts as a disability under your policy terms?

When you consider this question, you will likely find that the answer depends more on your insurance company than on you. Ultimately, the insurer's opinion determines what counts as a compensable disability. They must consider you, your injuries, and your claimed disability. They also consider policy language, independently generate medical data, and other factors.

Do You Need a Lawyer to Help You With Your Disability Denial?

If you want to feel confident in the disability claim-handling process, you need a legal professional on your side. Lawyers who handle ERISA-regulated disability claims recognize the obstacles you face. They understand the process, so they prepare and present your medical evidence with those challenges in mind. Whether you're submitting a new claim or dealing with a claim denial, an attorney protects your interests and intervenes on your behalf. They work within state, local, and federal guidelines to provide the best outcome possible. Reach out today for a Free Denial Review to discuss your long term disability denial and see how we can help.
J. Price McNamara Author Image

J. Price McNamara


Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!

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