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It’s no secret that insurance companies are happy to sell you a disability insurance policy and not at all willing to pay benefits when you suffer from a disability and need to file a claim. These companies have become experts at finding reasons to deny claims. The sad fact is that even when coverage should be clear and obvious, insurance companies dig themselves so deeply into the denial trench that many claimants are unable to receive benefits without the assistance of an attorney who focuses on resolving disability insurance claims.

One question that naturally arises for many disability insurance claimants is whether an insurance company can deny a claim because of the cause of the disability. And because we’re dealing with insurance, the answer is complex and varies depending on the circumstances involved. If you contact us directly, we can review the details of your situation and explain your rights. In the meantime, here is some general information on how the cause of your disability could affect your ability to obtain benefits under a disability insurance policy.

The Terms of the Policy Determine Coverage

When you buy disability insurance, you enter into a contractual arrangement with the insurance company. There are some laws that affect the contract, such as laws imposing an obligation to act in good faith. But the primary source of authority for interpreting the policy is the terms it sets out.

That means to determine how the cause of a disabling condition could potentially impact a claim for benefits under the policy, you need to comb through every sentence in the policy and understand the meaning assigned to each term. Insurance companies sometimes operate in their own language and use terms of art that may not be obvious to anyone who is not intimately familiar with disability insurance policies. What appears to be promised in the marketing materials may differ significantly from what is spelled out in the policy’s specific language.

An attorney who works with these policies daily can translate this insurance language and explain the obligations of both parties and the exceptions that apply under the policy.

Watch for Exclusions

One way the cause of a disability can affect the ability to receive payments under a disability insurance policy is if the cause of the disabling condition falls within a policy exclusion. Insurance companies specify that they will not pay in certain situations, but these situations may be described in language buried deep within the fine print near the end of a stack of documents.

Insurance companies will commonly exclude disabilities resulting from:

• Intentional self-inflicted injuries
• Injuries caused by war
• Injuries stemming from participation in an illegal activity
• Illnesses resulting from a protest or riot
• Pre-existing conditions

So, even if your condition meets the policy’s definition of disability, if the cause of the condition falls within the listed exclusions, the insurer has the right to deny the claim. However, there are many cases in which insurance companies insist on excluding a condition when, in reality, the cause of the injury does not fit into any exclusion category. For instance, the company might assume, or even insist, that an accidental injury was intentional. They might apply a very broad definition of situations that constitute a “riot.” Or they might claim that a policyholder was somehow connected with illegal activity that was actually quite legitimate.

Watch Out for Limitations

In some cases, the cause of a disability fits under a limitation in a disability insurance policy. This does not necessarily give the insurance company grounds to deny benefits completely, but it could allow the company to limit the duration of payments or the amount they will pay out.

Limitations are common for disabilities stemming from:

• Drug or alcohol use
• Cosmetic surgery
• Mental health diagnoses
• Organ transplants
• Injuries or illnesses related to travel abroad

Insurance companies will sometimes exclude or limit coverage for certain pregnancy conditions, particularly for policyholders who have had complications from pregnancy in the past.

Pre-Existing Conditions

One of the most common reasons disability insurance claims are denied is that the insurance company believes the disability stems from a preexisting condition excluded under the policy. These issues can be complex both medically and legally.

Any medical condition that was treated or diagnosed before a policy takes effect is considered a pre-existing condition under the policy. By some definitions, a policyholder must have sought advice about or treatment of a condition before it can be legally considered pre-existing. Other definitions define a condition as pre-existing if a reasonable person would have sought medical care for the condition based on its symptoms.

Sometimes a denial is justified, but in other cases, the insurance company makes irrational connections between a prior condition and a current disability. For instance, someone who suffered from chronic back pain due to a herniated disk could have their claim denied when filing a claim after a car accident caused fractured vertebrae. While it is true that the policyholder suffered back pain previously, the fractured vertebrae caused by the impact of an auto accident were not a condition that existed previously. An injury should not be excluded just because it occurred in the same part of the body as a previous injury.

In many cases, an experienced disability insurance attorney can demonstrate that a disability is not a pre-existing condition and that the claim under the policy should be approved.

When a Claim is Denied Wrongfully

Insurance companies operate to make a profit, so the reflex action to any claim seems to be to look for any potential reason to deny it. Exclusions often provide many justifications, so insurance companies will cite them in the hopes that the policyholder will accept the reasoning and not try to appeal the decision.

There are processes for appealing denials within the insurance company, but with many individual disability insurance policies, the internal appeals process is voluntary. An experienced insurance attorney can often determine the most effective course of action. 

Sometimes, communication from an attorney will be sufficient to encourage an insurance company to fulfill its obligations under the policy. Other times, it may be necessary to file a lawsuit to move the negotiation process forward. It is a good idea to work with an attorney with a reputation for success in litigation, even though most insurance disputes settle out of court. When an insurance company knows that a policyholder is working with a legal team that is prepared to win in court, they are more likely to see reason earlier in the process.

When You Need Help with a Disability Insurance Claim, Seltzer & Associates is Ready to Fight for You

When a disability is bad enough to prevent you from working, you need to be focused on recovery. However, it can be hard to do that when you are worried about supporting yourself. You’ve planned ahead and purchased disability insurance for an occasion just such as this. But the insurance company is not ready to live up to its end of the bargain.

At Seltzer & Associates, we have dedicated our practice to helping professionals get their disability insurance claims covered fairly. For a confidential, free consultation to learn more about the assistance we could provide in your situation, call us at 888-699-4222 or contact us online now.