Short-term disability benefits provide wage replacement when you cannot work. Benefits are available through an insurance policy you purchase from an insurance company, or they may be available in a few states, including California, with disability insurance programs providing short-term disability benefits.
Simply because there is a government-sponsored program or private insurance policy in effect does not automatically make you eligible for short-term disability benefits. Unless you meet the eligibility requirements of the insurance company or the state program, short-term disability can be denied. This blog post explains the top ten reasons short-term disability can be denied.
Reason 1: Your Condition Does Not Meet The Terms And Conditions Of The Plan
Disability insurance policies and state programs have eligibility requirements to qualify for benefits. For example, some short-term disability policies do not cover mental health conditions or elective surgery while other policies do. You must meet the terms and conditions of the policy.
The California program, State Disability Insurance, pays benefits for elective surgery, mental health conditions, and medical conditions that prevent you from working. However, it does not pay benefits for work-related injuries or illnesses because workers’ compensation covers those claims.
Reason 2: You Have A Pre-Existing Condition
Another one of the reasons short-term disability can be denied is for a pre-existing condition. A pre-existing condition is one you had before you acquired the policy or within a certain period after enrollment. Some policies prevent you from qualifying for a disability caused by a pre-existing condition.
Reason 3: You Lack Sufficient Medical Evidence To Prove The Claim
Claims for short-term disability must be supported by medical records documenting the condition and that it is severe enough to prevent you from working. The records must be from a medical professional and include a diagnosis, treatment plan, prognosis, and how long the condition is expected to last. Other supporting evidence may consist of lab and imaging results.
Reason 4: Failure To Follow The Treatment Plan Recommended By Your Doctor
If a physician or other medical professional providing care recommends a treatment plan for your condition, you must follow it. This includes taking prescribed medications. A claim for short-term disability can be denied when the insurance company determines that failing to do so interfered with your recovery or prolonged the disability.
Reason 5: You Are Partially Disabled
If you can perform some or all of the essential duties of your job, a short-term disability claim may be denied. Short-term disability benefits usually are not payable unless you are totally disabled and unable to work at your job.
Reason 6: You Do Not Meet The Eligibility Requirements For The Disability Plan
Each plan has its own requirements you must meet to be eligible for benefits. For example, you must meet the following criteria to file a claim for State Disability Insurance in California:
- Be unable to work at your customary job for at least eight days.
- Lost wages because of a medical or mental health condition.
- Paid into the State Disability Insurance program through payroll deductions on at least $300 in wages during a base period.
- Be under the care of a licensed health care professional within eight days from the start of your disability and remain under their care and treatment.
Private insurance plans and policies have their own eligibility requirements you must meet to file a claim.
Reason 7: You Are Disabled Due To A Work-Related Illness Or Injury
If you are injured in a work-related accident or become ill because of conditions related to your job, a claim for short-term disability benefits will be denied. Short-term plans, insurance policies, and government programs exclude work-related medical and mental health conditions.
Workers’ compensation would be your source for payment of medical care and lost wages resulting from injuries and illnesses related to your employment. Immediately notify your employer if you are injured or become sick because of an accident or conditions at work.
Reason 8: Fraud Or Misrepresentation About Your Claim
Any misrepresentation or omission of facts about your claim can result in a denial of benefits. Fraud and misrepresentation may subject you to civil or criminal penalties, depending on the circumstances.
Be honest about your condition and the extent of your disability when filing a claim for short-term disability. Exaggerating or faking symptoms to make your claim appear stronger will only backfire on you.
Reason 9: Failing To Cooperate With The Plan Or Insurance Company
The terms and conditions of short-term disability policies and plans require that you cooperate. For example, a disability insurance company may want an independent medical evaluation by a medical professional of their choice or request additional information to evaluate the extent of your disability. Your short-term disability can be denied if you fail to cooperate fully.
Reason 10: Inconsistencies In The Information You Provide About Your Claim
Short-term disability plans carefully review the information you provide on your application and after you begin receiving benefits. Mistakes happen, but too many inconsistencies may cause an insurer to doubt whether you are entitled to benefits, leading to a denial.
Get Help From A Disability Lawyer
If a claim for short-term disability benefits is denied, you may have the right to appeal the decision. Learn about your rights at the disability law firm serving people throughout Northern California for more than four decades. Contact Sackett Law today for a free consultation.
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