A denied short or long-term disability claim can turn an already difficult medical situation into a financial crisis. Many people in Western Pennsylvania rely on disability benefits when a serious injury or medical condition prevents them from working. Yet insurers often deny claims based on technicalities, incomplete documentation, or interpretations that favor the company, not the claimant.
At AlpernSchubert, P.C., in Carnegie, our attorneys help individuals throughout Western Pennsylvania challenge wrongful disability denials, correct insurer missteps, and preserve their rights under employer-sponsored and private disability policies. Understanding why insurers deny claims (and the tactics they often rely on) gives you a clearer path forward in the appeals process and helps ensure you take the right steps to protect your benefits from the start.
Why Short or Long-Term Disability Claims Get Denied
Insurance carriers deny disability claims for many reasons, but some patterns appear over and over. Common bases for denial include:
Insufficient Medical Evidence
Insurers often argue that medical records do not provide enough documentation of symptoms, limitations, or functional restrictions. Even when a treating physician supports the disability, missing records or vague chart notes can lead to a denial.
Claim Filed Too Late
Many short and long-term disability policies have strict deadlines for filing claims, providing notice of disability, or appealing a denial. Missing even one deadline, even unintentionally, can jeopardize your rights.
Insurer’s Doctor Disagrees With Yours
Insurance companies frequently rely on in-house medical reviewers who have never treated or examined the claimant. These reviews often minimize the severity of a condition or claim that you can return to work despite significant limitations.
Disagreement About “Own Occupation” vs. “Any Occupation”
Most disability policies offer benefits if you cannot perform your “own occupation” for a set period, then shift to an “any occupation” standard later. Insurers often deny claims at this transition point by asserting, sometimes incorrectly, that you can perform some type of sedentary or alternative work.
Next Steps After a Short or Long-Term Disability Denial
A denial letter is not the end of your claim. You have the right to appeal, but the steps you take immediately after receiving the denial can significantly affect the outcome.
Carefully Review the Denial Letter
The letter should outline:
- Why the insurer denied your claim
- What evidence the company relied on
- Deadlines for appeal
- Required forms or additional documentation
Understanding these details is crucial before taking action.
Request and Preserve Your Entire Claim File
Under ERISA, you are entitled to obtain the full administrative record, including medical reviews, vocational assessments, internal notes, and any surveillance results. This file becomes the foundation of your appeal.
While many disability denials fall under ERISA, some private, individually purchased policies follow different rules; however, strengthening the record and preserving every document is critical in both types of claims.
Seek Additional Medical Documentation
Strengthening the medical record is essential. This may include:
- Updated office notes
- Imaging or diagnostic studies
- Functional capacity evaluations
- Detailed physician statements
Many initial denials stem from file gaps that can be corrected with thorough documentation.
Avoid Giving Statements Without Guidance
Insurers often request interviews or written statements after a denial. These interactions can unintentionally harm your claim if not handled carefully. Speaking with a Pittsburgh disability lawyer first can help you avoid common pitfalls.
File a Comprehensive, Evidence-Based Appeal
In most disability cases governed by ERISA, you typically get only one opportunity to submit evidence before the file closes. A strong appeal should address the insurer’s reasoning, challenge flawed medical reviews, and include the strongest possible medical and vocational evidence.
Common Traps That Can Undermine Your Disability Appeal
Insurance companies often use predictable tactics to weaken claims. Being aware of these traps can help protect your rights.
Incomplete Medical Records
If a treating provider fails to document symptoms consistently, insurers may argue that your condition is improving even when it isn’t.
Surveillance Footage
Insurers may conduct video surveillance or social media monitoring. Innocent activities, such as lifting a grocery bag or walking briefly without assistance, can be misinterpreted as proof that you can work full-time.
Functional Capacity Assessments Designed to Fail
Some insurers push claimants toward evaluations that are not representative of a typical day or that exceed the individual’s actual abilities. Overexertion during these tests can skew the results.
Relying on the “Any Occupation” Standard
When your policy shifts to the stricter “any occupation” requirement, insurers often assert that you can perform sedentary jobs, even if no such job is realistic given your condition and training.
Missing Appeal Deadlines
Appeal deadlines in disability cases are strict. Missing the window, even by one day, can eliminate your ability to pursue the claim further.
Why Legal Representation Matters in Short and Long-Term Disability Appeals
Short and long-term disability cases are complex, deadlines are unforgiving, and insurers have significant resources working against you. Many claimants are unaware that the appeal stage is the most critical phase, especially under ERISA, because it is often your last chance to submit evidence before the record is closed.
At AlpernSchubert, P.C., our Pittsburgh disability lawyers:
- Review denial letters and identify weaknesses in the insurer’s reasoning
- Collect and organize medical and vocational evidence
- Prepare comprehensive, legally grounded appeals
- Challenge incomplete or biased insurance reviews
- Advocate for clients throughout Western Pennsylvania facing wrongful disability denials
Having experienced legal guidance early in the process helps level the playing field and ensures your claim is positioned as strongly as possible from the outset. You’re not powerless. You need to act strategically. We can guide you.
Denied Your Disability Claim? Get the Guidance You Need.
If your short or long-term disability claim was denied anywhere in Pittsburgh, Allegheny County, or the surrounding Western Pennsylvania communities, you do not have to navigate the appeal on your own.
Call AlpernSchubert, P.C. at 412-556-2326 or contact us online to schedule a confidential case evaluation with a Pittsburgh disability lawyer. We are here to protect your rights and help you move forward with clarity and confidence.
Disclaimer: The articles on this blog are for informative purposes only and are no substitute for legal advice or an attorney-client relationship. If you are seeking legal advice, please contact our law firm directly.