What to Do When Your Disability Insurance Claim is Denied

The problem

Amy Rangel, 54, has long lived with postural orthostatic tachycardia syndrome (POTS), a condition marked by a racing heartbeat, fatigue and dizzy spells. Last year, Rangel, then a math lecturer at Northern Arizona University in Flagstaff, was suffering so much that her doctors recommended she stop working. When she applied for short-term disability, however, her group insurance carrier denied the claim, asserting that she’d failed to show she couldn’t do her job. Rangel appealed, setting off a series of missed communications between her doctors and the insurer that dragged on so long that she filed for long-term disability — which was immediately approved. But Rangel needed the $15,000 in missing short-term payments to cover her bills. “We have been living on my husband’s Social Security and our retirement savings,” she wrote me.

The advice

The public relations department at MetLife, Rangel’s carrier for group short-term disability insurance, said the company doesn’t comment on specific claims. Instead, MetLife provided me with information about common filing mistakes and the appeals process. I also spoke with Emily Brown of the nonprofit Patient Advocate Foundation and Ellen Bresnahan, president of Insurance Appeal Consultants in Burke, Virginia, which handles long- and short-term disability cases. If you need to file a claim or appeal, here’s what you need to know and do.

Learn the rules. Ask your human resources department for a copy of your plan, read it and try to understand it (which may not be easy). Deadlines, says Brown, are the “low-hanging fruit when it comes to denials.” And every policy is different. Although most give you 30 days to file a claim, some give you just five business days from the first day you’re unable to work.

See an M.D. ASAP. Go to your doctor, an ER or urgent care to document why you can’t work. Several factors probably worked against Rangel. One, she had no clear date or incident. Two, her first medical appointment after filing her claim was with a physical therapist; POTS is typically treated by a cardiologist. Three, her next visit, to a naturopathic doctor — not an M.D. — didn’t likely help. “Any nontraditional treatment seems to be dismissed by insurance company doctors,” says Bresnahan.

Keep a symptom journal. A record of your condition that you can share with your doctor will help with your application or appeal. A journal should focus on the intensity, frequency, duration and functional impact of your symptoms to show how they would interfere with working an eight-hour day and 40-hour week. If you have migraine headaches, for example, beyond saying that the pain on a certain day was a 10 out of 10, you might note that when that happened, you couldn’t sit at your desk or look at your computer, and you lay down a certain number of hours in darkness before recovering.