Why Was My Short Term Disability Claim Denied?

Short term disability (STD) insurance is designed to replace a portion of your income temporarily if you become disabled and are unable to earn an income. A disability can result from an injury, a serious illness or a mental health issue.

STD comprises of paid sick leave days, STD benefits from private insurance companies, Employment Insurance Sick Benefits, ICBC Part 7 Disability and WorkSafe BC benefits.

STD benefits from employers are indemnity plans administered through an insurance or health management company, while coverage from the other insurance programs are government regulated.

Short-term Disability Insurance Plans in BC

STD benefits begin payment after a specified number of days of the qualifying period, from the last day worked or after exhausting paid sick days. These short qualifying periods help reduce administration for claims of really short duration. Under an STD plan, disability is linked to the employee’s inability to perform any or all aspects of their occupation. Here are the general definitions for each of these short term disability insurance plans in BC:

1) Paid Sick Leave Days From Employer

You are required to use your accrued sick days first, up to a maximum set under the employment and insurance policy for sick leave if your employer provides this benefit. Paid sick days provide income protection when employees are ill, injured or caring for an ill family member. This may include a child, spouse, parent, parent-in law and same-sex domestic partner, depending on the policy.

2) Short Term Disability Benefits With Private Insurers

STD benefit payments begin after the last calendar day of sick leave coverage and continue for the duration of the disability to a maximum of the short term disability policy days. This STD provides salary protection for the employee or self-employed insured who is unable to work for a period of time due to a non-work related illness or disability. The private insurer will require certification of illness and disability from your physician or an independent medical examination (IME) with their own physician to verify the continued absence is legitimate.

Most short term disability policies from private insurers are up to two years in coverage. If the disability continues beyond this period, you could be qualified to apply for long term disability from either a private plan or Canada Pension Plan Long-term Disability.

3) Employment Insurance (EI) Sick Benefits

If you do not have a short term disability policy with a private insurer, you may apply at Employment Insurance (EI), a federal government program for temporary financial assistance to unemployed workers who are unable to work because of sickness, injury, or quarantine for medical reasons. If you qualify with the minimum insurable hours, and after the one-week waiting period as of 2016, you could be eligible to receive up to a maximum of 15 weeks of EI sickness benefits. You will need to obtain a medical certificate signed by your doctor or approved medical practitioner. Visit EI Sick Benefits for details.

4) Working, Injured and Disabled from a Motor Vehicle Accident?

ICBC Part 7 Benefits for short term disability are up to two years and is considered secondary coverage. Therefore, you must apply for primary disability coverage from any disability plans available to you through your employment or through a spouse’s employment. If there are no other disability plans, you will need to apply for Employment Insurance Sick Benefits or WorkSafeBC if applicable, before any shortfall coverage is available from ICBC Part 7 Benefits for short-term disability. Learn More About ICBC Claims and Primary vs. Secondary Coverage. 

5) WorkSafe BC Disability Benefits from Work Injuries or Disease

If you have a work-related injury or disease, you will need to seek medical attention and report your injury to your employer. If you miss work or seek medical attention, you must report to The Workers’ Compensation Board of British Columbia aka WorkSafeBC, governed under the Workers Compensation Act. If you’re injured on the job and unable to work, call WorkSafeBC Teleclaim at 1.888.967.5377 to make a claim. (www.WorkSafeBC.com)

Please note that our firm does not represent people seeking to challenge WorkSafeBC disability claim denials.

 

Why Are Short term Disability Claims Denied?

Insurance companies often deny short term disability claims. There are six main reasons for these types of disability claim denials:

  1. Lack of Proof of Short Term Disability
  2. Changes in Medical or Functional Status
  3. Short Term Disability Denied After Time Limit
  4. Change of Definition for Own Occupation
  5. Exclusion for Pre-existing Conditions
  6. Failure to get Regular and Appropriate Physician Care

For the complete details on why disability claims are denied, visit six most common reasons for insurance companies to deny disability benefits.

Other Factors Influencing Short Term Disability Denials

Short term disability denials can also be related to application errors or insufficient evidence, while other denials occur because the situation does not meet the criteria for an STD claim. About two-thirds of all initial claims for disability benefits are denied, even seemingly credible ones. Here are some influencing factors for STD claim denials:

1) Private Investigation With Video Surveillance Reveals you Have Exaggerated your Injury or Illness

Video surveillance may be involved as long as it does not violate your personal privacy. Recordings are allowed as long as one party is aware of the recording. An invasion of your right to privacy may occur if an investigator is snooping around your home, knocking on your door under false pretences, i.e., pretending to be someone they are not, following you too closely in public places, or acting in an unreasonable or intrusive manner.

2) Your Social Media Posts

People usually post pictures of themselves in social situations smiling on social media. That’s because if you point a camera at someone, they are conditioned to smile – even if they are in pain. Also someone suffering emotional trauma may not want their friends and family to know how much they are suffering – so they choose to post only content that makes them appear well.

If social media posts are produced as evidence, the weight of those images for or against the claimant case is at the judge’s discretion. Both personal injury and short term disability cases are increasingly submitting evidence from social media, with the hope these posts will negate your claims. The takeaway is to be prudent about what you post on social media if you have been injured.

3) Report from Independent Medical Examiner that Contradicts your Injury or Illness

The insurance company will require you to attend an independent medical examination (IME) with their doctor. The doctor will evaluate your ability to function and respond physically and/or mentally to various tasks. They may make recommendations or restrictions on your ability to perform daily activities at home, work and recreation. The IME report is often used to confirm or deny short term disability benefits, other coverage and settlements.

4) Need Help With Your Short Term Disability Claim Denial?

You should not delay in getting legal advice to clarify definitions and deadlines for short term disability plans. Speak with one of our experienced lawyers if your STD claim is denied. You may be concerned about not having money to hire a lawyer, but we could represent you on a contingency for an agreed percentage.

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