The biggest mistake people make with their Short-Term Disability (STD) appeal is to try to explain their claim themselves, without relying on any medical support. This happens most commonly with claims that are based on mental health conditions, like depression and anxiety, but they can happen with any claim where you work as long as you can until you just can’t take it anymore and then stop and apply for disability benefits.
That’s a legitimate way to start a Short Term Disability claim. The problem comes when the thing you do next is not to see your doctor, it’s to focus on trying to get your insurance company claim representative to understand why you stopped working. You might describe increasing difficulty just getting out of bed, let alone being functional at work. Or an increase in panic attacks. Pain that just won’t quit. Unrelenting fatigue. Whatever the reason, you (very legitimately!) just need a break to reset, because you’ve come to a point where you can no longer do the things you need to do for your job. You absolutely fit the Short Term Disability definition of “Disabled” – there’s no question about that.
So it comes as a huge shock when your claim is denied. Talk about getting kicked when you’re down. Sometimes it happens even after the claim manager seemed so nice and sympathetic. Clearly the denial was a mistake, and the denial letter makes appealing sound so easy…it says something like, “just give us the reasons why you feel our decision was incorrect.” A reasonable response would be to explain harder, give more detail about why you just are not able to work right now. But that’s a trap! Send that strongly worded letter as your appeal, and it is sure to be denied.
It’s not you, and it’s not that your explanation was lacking. Often, it’s not even that your claim manager didn’t believe you…their sympathetic ear may have been genuine. But the system just isn’t set up that way. The SYSTEM that the insurance company uses to decide disability claims runs on “proof of claim.” It cares very little about what you have to say. “The System” is set up to evaluate what your DOCTOR has to say about your claim, both directly through the claim forms they fill out, and indirectly through your medical records that record exam and test results. The insurance company is looking for a “match” between what your doctor says on the forms (that you have restrictions or limitations that prevent you from working) and what they described in the office visit notes when they examined you. When these two things match, that’s “proof of claim,” and it’s the surest way to get your claim approved.
If there’s a mis-match (if the forms say you’re disabled but the office visit notes say everything is normal, for example), that can lead to a denial. When the forms and/or medical records are sparse or missing altogether, the claim is sure to be denied. The appeal will be denied, too, unless you add medical evidence that supports your claim. Every policy is unique, but they all require “proof” that you are disabled, and the only “proof” that makes sense to the insurance company comes from your doctors and your medical records.
Giving context for your claim is important. In science terms, though, it’s considered “necessary, but not sufficient.” The biggest mistake you can make with your Short Term Disability appeal is being the only one providing the context and explanation for your claim. Building a successful appeal is a team effort, and your doctor(s) have to be on the team.
As soon as you know you’re no longer able to work, the best thing you can do for your disability claim and appeal is to 1) see your doctor, 2) explain to THEM why you’re unable to do the specific things you need to do for your job, and 3) follow through with their testing and treatment recommendations to document the extent of your disabling symptoms. Presenting that substantive evidence to the insurance company will give you much greater odds of winning your appeal and having your claim approved.
Looking at a denial letter and not sure where to start? Let us help! We’ll review your denial letter for free and tell you what we think you need to do to build a successful appeal.
