Reason for Denied Short-Term Disability Claim
You’re hurt, and you can’t work. You apply for short-term disability benefits through your employer, but then you get the letter no one wants to see: “Your claim has been denied.” What are the reasons your short-term disability can be denied? And what can you do about a denial? In many cases, you can answer these questions by carefully reading your policy and appealing unfavorable decisions.
At the Peace Law Firm, we help workers in South Carolina understand their rights under employee benefit plans governed by ERISA and state insurance law. We have been doing this for more than 20 years. If your short-term disability claim was denied, you’re not alone—and you’re not powerless. Let’s walk through the common reasons why short-term disability may be rejected and how we can help you get benefits.
Why Would Short-Term Disability Be Denied?
You have the right to rely on the disability benefits you paid for. Unfortunately, insurance companies don’t always cover claims. Denial letters can be vague, frustrating, and full of technicalities.
But you have a legal right to challenge your rejection. The first step is understanding the common reasons short-term disability can be denied.
Untimely Claims
Short-term disability policies may require strict compliance with deadlines. If you fail to give timely notice of your claim or delay submitting proof of loss, an insurer might deny your benefits outright.
Many policies require that you give written notice of a claim within 20 days and submit proof of loss within 90 days, unless it is not reasonably possible.
Report your claim to your employer and the insurer as soon as you stop working. Keep records of all notices and communications. Even if you miss a deadline, submit your documents immediately with an explanation. A late filing could be excused if the circumstances were out of your control.
Insufficient Medical Evidence
Even if you file your claim on time, you might miss out on coverage if you don’t provide enough medical documentation of your disabling condition. If your claim lacks the correct language, timelines, or physician statements, the insurer may argue there’s not enough proof to warrant paying out benefits.
Asking your doctor to specify work restrictions and how your condition limits your job duties can help improve your health and access to short-term disability benefits. Speaking to an experienced ERISA attorney can also maximize your access to benefits. The Peace Law Firm can help you collect and submit the most complete and up-to-date medical records for coverage.
Preexisting Conditions
Many policies exclude disabilities related to preexisting conditions, especially if the condition appeared within the first 12 months of coverage. If you had symptoms or treatment before your coverage began—even if you didn’t know the diagnosis—your claim might be denied.
Carefully review the timeline of your medical history and your insurance effective date. You may still qualify for benefits if your condition was previously dormant or stable.
Changes in Occupation
For individual short-term disability policies regulated by South Carolina insurance law, your coverage and premiums are often based on your occupation’s risk classification. If you change to a more hazardous job after your policy starts, your insurer may reduce your benefits or deny coverage for certain claims.
However, if you’re covered under a group short-term disability plan governed by ERISA, different rules apply. ERISA requires insurers to follow the written terms of the plan. That means your benefits generally cannot be reduced or denied simply because your job became riskier, unless the plan specifically includes that limitation. ERISA preempts many state rules, so it’s critical to review your plan documents carefully or speak with an attorney at the Peace Law Firm familiar with both state and federal disability laws.
Intoxication or Substance Use
If your disability resulted from being under the influence of drugs or alcohol, you might be denied coverage. South Carolina law permits insurers to exclude coverage for losses resulting from intoxication—unless the substance was prescribed and taken as directed by a physician. For ERISA-governed group disability plans, exclusions for intoxication may also apply, but only if they are clearly stated in the official plan documents.
If a substance was involved in your accident or illness, be transparent with your attorney about it. Gather documentation to show you were following medical advice if a doctor prescribed the substance you used. Proving your right to benefits when an insurer claims you were under the influence may be tricky, but it’s not always impossible. The Peace Law Firm has decades of experience crafting the best arguments and appeals for our clients.
We Can Help Get the Benefits You Deserve
You don’t have to stop fighting when you’re denied short-term disability coverage. Let the Peace Law Firm take up the battle. Attorney John Peace is a top-rated advocate with decades of experience and a trusted leader in the South Carolina legal community.Contact the Peace Law Firm today for a free consultation. We’re ready to help you take control of your story and get the support you need.
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