Last reviewed October 27, 2026 by Vivek Sharma, licensed Pennsylvania insurance producer (License #719000).
Many disability claim denials trace back to decisions made when the policy was bought or the application was filled out. Knowing the common reasons helps you avoid them.
Common reasons claims are denied
- Not disabled under the policy’s definition. The insurer decides you can still work under the contract’s definition, or that your loss of income isn’t large enough to qualify.
- Insufficient documentation. Medical records, physician statements or financial records don’t support the claim, or weren’t provided.
- Pre-existing condition. The condition existed before coverage began and falls within the policy’s pre-existing condition limitation.
- Excluded condition. The policy excludes or limits the condition, for example through an exclusion added at underwriting, or a limit on mental health or substance use claims.
- Excluded circumstances. Such as acts of war, committing a felony, or an activity the policy excludes.
- Misrepresentation on the application. Incomplete or inaccurate answers about health, income or occupation can lead to a denied claim or a rescinded policy.
- Elimination period not satisfied. For example, returning to work before the waiting period ends.
- No coverage in force. The policy had lapsed, or the claimant wasn’t covered on the date the disability began.
Reducing the risk before you need to claim
- Answer the application completely and accurately. Include medical history and income details, even when they seem minor.
- Choose the right definition of disability. An own-occupation definition is easier to meet for a specialist than any-occupation.
- Read any exclusions added at underwriting before you accept the policy, and ask whether they can be reconsidered later.
- Keep the policy in force with automatic premium payments.
- Keep good records of income and of your medical care.
If your claim is denied
Read the denial letter carefully: it should explain the reason and how to appeal. Claims under employer-sponsored group plans are generally governed by federal ERISA rules, which require you to complete the plan’s internal appeal, usually within 180 days, before going to court. Individual policies are governed by your policy and state law, and Pennsylvania residents can contact the Pennsylvania Insurance Department with concerns. For a significant claim, consider consulting an attorney who handles disability claims.
General information, not legal advice.
Our clients don’t go through a claim alone: if you ever need to file, we help you through the process.
Related: Own-occupation explained · Disability Insurance Guide