Reasons Short-Term Disability Can be Denied (+ STD Appeals)

Did you recently go on a sick leave from work? Did the insurance company hand you back a short-term disability denial letter? Are you unsure of what to do next? If you answered yes to any of these questions, keep reading. This article overviews everything you need to know about short-term disability denials, including reasons short-term disability can be denied, how to appeal, and more.

For more information on short term disability in general, check out our article, what qualifies for short-term disability? It overviews the basics, including what it is, how to apply, how much it pays and more.

Can short term disability be denied?

Yes, short term disability claims can absolutely get denied! You can be denied for a variety of reasons. Some of the most common reasons include failure to comply with treatment, lack of support from your doctors, an inability to prove the seriousness of your symptoms, etc.

But don’t worry. In the sections below, we elaborate more on questions like whether you can be denied short-term disability coverage, as well as what you can do about it.

Need help appealing short term disability denial?

Appealing a short term disability denial can be difficult — especially when you have no experience with the process. With that said, a denial isn’t the end of the world. You have options: you can appeal it on your own or contact an experienced STD lawyer. Both options are great. However, hiring a disability lawyer can give you more peace of mind as you will know your claim is being handled by someone who is experienced and understands the process.

Here at Resolute Legal, we have helped countless people overturn short term disability denials, and we can help you, too! Using The Story Alignment Method ™, our proprietary system for managing disability claims and appeals, we are confident we can get you a result you can be happy with. 

Get started today, call our our support team at (888) 480-9050 or click on the button below to schedule a FREE disability consultation.

10 Reasons short-term disability can be denied

Short-term disability can be denied for a variety of reasons. The most common are lack of doctor support, insufficient medical evidence, and pre-existing conditions. Unfortunately for claimants, however, there are many more. Insurance policies are very specific, so make sure to read your benefits booklet before making assumptions.

Let’s dive in! 

So, the story usually goes something like this: You have been struggling at work due to illness or disability. You worked as long as you could but have reached a crisis point. If you don’t take a sick leave soon, you will break down. You got your doctor to fill out the paperwork for short-term disability benefits, but your claim was denied. You are stunned because you are 100% unable to work right now and, on top of that, have no idea what you did wrong. 

Getting a denial letter can be a tough pill to swallow — we know that. But understanding the reasoning behind a denial will give you the best chance of reversing that decision.

1. Your symptoms aren’t serious enough to qualify for short-term disability

Your short-term disability may get denied because your symptoms don’t appear to be serious enough. This can be another way of saying that you don’t have enough medical documentation. Unfortunately, the insurance company needs more than just your own account of your symptoms.

What you can do: You might need to get extra confirmation from your doctor and ask them to provide documents that show the seriousness of your symptoms and how they prevent you from working.  

2. Your medical records don’t show a serious disability

This is similar to the issue above. In this case, when the insurance company looks at your medical information, nothing indicates that you have a serious condition. This doesn’t mean that there’s nothing serious going on —  it just means that your records don’t properly reflect it. 

What you can do: You will have to get more documentation from your medical team. Your doctor can further describe your symptoms and the treatment you require, for example.

3. Pre-existing conditions

Many people don’t realize that a short term disability claim can be denied because your disability presented itself before your insurance coverage started. Under most insurance policies, a condition is considered pre-existing if you received treatment for it within a certain time frame, often referred to as the pre-existing period. Each policy will have a different pre-existing period; however, most range from 6 months to two years. If the insurance company has reason to believe your condition is pre-existing they can certainly deny your claim.

What you can do: If the insurance company attributes your denial to a pre-existing condition, you should contact a disability lawyer immediately. These kind of cases are extremely complicated, one wrong move and you could jeprodize your entire claim. Call our disability support team at (888) 480-9050 for a free consultation. 

4. Your treatment doesn’t indicate a serious disability

There’s a misconception that if you have a serious condition, you will receive serious treatment. But the two don’t always go hand in hand. If the insurance company doesn’t see enough treatment or the right kind of treatment, they may provide this as a reason for your short-term disability denial. 

Depending on your diagnosis, there are standards of practice in the medical community. This means you should be treated a certain way for a certain condition. The insurance companies will have doctors reviewing your treatments with these standards in mind, and if your treatment doesn’t align with them, you may get slapped with a denial letter. 

What you can do: The remedy? Make sure your doctor is following best practices and treating you accurately. This might mean you have to go see specialists and try medication to match the commonly perceived “seriousness” of your condition.

5. You’re not sick —  you’re in a toxic work environment

The insurance company might give this reason, but what they are really saying is they don’t think you have a disability — it’s drama. You’re not sick; you just want to leave your toxic work environment. 

Just because work stress has caused you to leave doesn’t mean you shouldn’t qualify for disability. 

What you can do: When dealing with your insurance company, don’t overstate how bad your work environment is. If the insurance company can argue that the environment just needs to clear up and you’ll be fine, they will try to push that narrative. 

Obviously, this is highly oversimplified. In any case, you should bring up these problems with your employer to make sure they’re being corrected in the workplace. 

5. Short-term disability does not cover parental leave

Sometimes, the insurance company believes that you just want to stay home with your kids. They won’t say this outright, but it may be heavily implied. If you’re off on sick leave and also happen to have young children, they might be skeptical about the truth of your claim. 

What you can do: This type of situation gets dicey fast. In these situations, we encourage you to get legal advice as soon as you can. You have to be cautious of how you present yourself and careful with what you say when you interact with your insurance company.

6. Your doctor doesn’t support that you have a disability 

Sometimes, doctors will be against their patients. For example, we’ve seen doctors write that they don’t think their patient has a disability. Or, they’re on the fence, and they simply aren’t saying enough in their records. They might include very general information —  but no outright support. 

What you can do: If your short-term disability gets denied because of this, it’s one of the easiest things to fix. A lot of doctors have good intentions and are just mistaken about what’s required for you to go on sick leave. Sometimes, you will have to educate your doctor about what’s required and prove to them that you’ve done everything you can to get better. Once you have done this, their records should show their support.

7. Over exaggerating or lying in your application

Many people erroneously believe that they have to make their condition seem worse than it actually is to get approved for short term disability. This is FALSE! Lying or over-exaggerating is one of the worst things you can do. 

Why? In order to win disability claims, you must be viewed by the decision-maker (i.e., the person who approves or denies your claim) as a credible, honest person. If they see inconsistencies in your application or have a suspicion that you may be lying or over-exaggerating, there is a high chance they will deny your claim.

What you can do: Be honest in your application, and don’t over-exaggerate your symptoms. If you’ve already lied in your application, own up to your mistakes. Taking responsibility and not blaming others is a great way to rebuild your credibility. In addition, you should talk to a disability lawyer, once the cat is out of the bag that you were decietful it can be difficult to get the decision-maker to change their mind.

8. Unfavourable surveillance evidence

While surveillance is much more common for people on long term disability insurance claims, it can also happen to people on short term disability. What is surveillance? Surveillance is when the insurance company hires a private investigator (PI) to surveil you either online or in person. The goal of surveillance is to catch you lying about or faking your disability. For example, if you say in your application or to your case manager that you can’t stand for more than 10 minutes, a PI would want to get a recording of you standing in line at Tim Hortons for 30 minutes. You get the drift. 

If the insurance company gets their hands on unfavourable surveillance evidence, it could give them grounds to deny your claim.

What to do: In your application, don’t over-exaggerate your symptoms or speak in absolutes unless they are actually true. For example, don’t say, “I can never stand for more than 10 minutes,” if in reality you sometimes can. Instead, say something like: “I usually can’t stand for more than 10 minutes, but on good days, I can.” We also recommend adding “to the best of my knowledge” at the end of every questionnaire or description of disability. This will again prevent you from speaking in absolutes and provide a layer of protection if your statements contradict surveillance evidence. If your claim has already been denied due to surveillance, we recommend speaking to a disability lawyer, oftentimes, insurance companies are looking for a gotcha moment so they may use evidence that is taken out of context to deny your claim. We can help you show the insurance company that their surveillance proves nothing. 

9. No diagnosis 

Technically, you don’t need a diagnosis to get approved for short term disability benefits. However, sometimes, if you don’t have enough medical documentation of your symptoms and how they prevent you from working, then the lack of diagnosis can cause problems. Oftentimes when an insurer denies you over a lack of diagnosis, they will mask the actual reason by contributing the denial to “a lack of objective medical evidence.”

What to do: Work with your doctors to figure out a diagnosis, see specialists and make sure to get as much documentation of your symptoms as possible. If you are still getting denied diagnosis issues, contact a disability lawyer as soon as possible.

10. Your condition is “excluded”

Some short term disability policies have a list of conditions or scenarios where, if a disability arose from that, they are “excluded” from coverage. The following are some common examples of scenarios where if a disability arose under these circumstances, a person could be denied benefits:

• The commission or attempted commission of a criminal offence;
• Active participation in a riot;
• Disability caused during incarceration;
• When an insured person fails to remain under continuing medical care, e.g. refusing to participate in a rehabilitation program or psychological assessment;
• Disability due to war declared or undeclared, or any act of war;
• Workplace injuries that can be made under a WSIB claim;
• Illnesses that arise within the first 90/365 days of the effective date of the policy;
• Intentionally self-inflicted injuries and
• Pre-existing conditions

These are just common examples. Always check your policy or group benefits booklet before making any assumptions.

What to do: If your condition is excluded, there may not be anything for you to do. However, exclusionary clauses aren’t always black and white; always consult with a disability lawyer before accepting a denial as is.

You’ve had short term disability denied, now what?

Now that we’ve discussed some common reasons for a denial let’s talk about your options moving forward. Below are the six things you can do after a short-term disability denial. 

1. Go back to work

This may not be an option, but it’s possible you were denied because you are well enough to work. Be honest with yourself on this. If you know you can’t work, then skip this option.

Not returning to work after short term disability?

If you aren’t planning on returning to work after a short term disability denial, you have the following options:

• Appeal the denial (internally or externally)
• Apply for EI Sickness
• Apply for long-term disability benefits
• Appeal the long-term disability denial
• File a lawsuit against the insurance company

2. Appeal short term disability denial

Your second option is to appeal the denial. The appeal procedures are usually the same regardless of what short-term disability plan you’re enrolled in. However, you should always check with your insurer to learn more about their specific appeal process. 

How to appeal short term disability denial yourself (internal appeal)

The first step in any plan, however, is to notify your plan administrator that you want to appeal the decision. After that, you will be given a deadline to submit your appeal. Deadlines vary, but they are usually around 90 days. Some plans are stricter about deadlines than others, but generally, we recommend sticking to the date they provided. If, for any reason, you think you can’t make that deadline, contact your plan administrator and ask for an extension.

Once you know the deadline, gather all the information needed for your appeal. This is often the hardest part of the process. You may have thought your previous application included everything you needed to get approved. If you are unsure about what information you should submit along with your appeal, reread your denial letter. The insurance company is required to provide their reasons for your denial in this letter. So, think of this document as your guiding compass when it comes to preparing your appeal. Look at their reasons and make sure your denial letter addresses them all. For example, if your denial letter points to a lack of treatment, you should include documentation of your new treatment plan. 

Once you are satisfied with your appeal, you can send it off. Insurance companies will usually take around 30 days to get back to you with a decision. If they approve your claim, great, but if they deny it, you can usually appeal it again. Most insurance companies allow you to appeal up to three times. To be clear, this kind of appeal is done directly with the insurance company. It is referred to as an internal appeal. We call it “internal” because, at this point, it only involves you and the provider.

How to appeal short term disability denial externally

There is another option, though. Instead of doing another round of internal appeals, you can opt for an external/legal appeal. This appeal involves an outside party, usually a judge or arbitrator, who ultimately makes the decision. At this point, we highly recommend hiring a lawyer. Oftentimes, there are unwritten reasons for a denial; an experienced disability lawyer will have a better sense of what the real reasons are and can create a strategic plan to address them.

3. Apply for EI Sickness benefits

If your short-term disability appeal is denied, but you are not well enough to return to work, then your next best option is to apply for Employment Insurance (EI) sickness benefits. EI Sickness benefits are a Federal Government Program paid by Service Canada. They will pay you 55% of your pre-disability weekly income for up to a maximum of 15 weeks. Applicants can fill out an application online or at a Service Canada office. You will need to get a Record of Employment from your employer that shows you are on medical/sick leave from work. You will need your doctor to certify that you are unable to work due to illness. EI sickness benefits will give you 15 weeks of payments.

4. Apply for long-term disability benefits

If you are still not able to work after 15 weeks, then you need to apply for long-term disability benefits. You should apply for long-term disability benefits even though your short-term disability claim was denied. While it is almost certain the insurance company will also deny your long-term disability claim, you need the application and denial to happen so you have more options.

5. Appeal the long-term disability denial

You have the option to ask the insurance company to review its decision to deny your long-term disability claim, but this really has a very low chance of success unless you have some new information or medical information that was not already given to them. If you don’t have new information, then you should just skip this step.

6. File a lawsuit against the insurance company

If the insurance company denies your long-term disability claim and you are still not able to work, then your next step is to file a lawsuit against the insurance company. Speak with a disability lawyer to learn about your options. You may be concerned about not having money to hire a lawyer, but there are disability lawyers across Canada who could represent you on a no-win, no-fee basis. Call Resolute Legal at (888) 480-9050 to learn more about your options.

What happens if short term disability is denied?

If your short term disability gets denied, you will receive a letter from the insurance company informing you that your claim was denied. In some cases, you may also hear the news from your case manager over the phone before you receive an official letter.

As discussed, you have options after a denial you can appeal it, apply for EI Sickness or long term disability, return to work or file a lawsuit.

Short term disability appeal help

At Resolute Legal, we focus exclusively on handling disability claims, including short and long term disability, CPP Disability, workers’ compensation and employment disputes. We have helped thousands of Canadians win back the benefits they deserve.

With a success rate of 94.65 percent across all matter types as of January 2024, we are confident our team can help you get a result you can be happy with. Please note: This statistic is based solely on cases that received a final determination, meaning it does not include clients who dropped the appeal. In addition, past results are not necessarily indicative of future results and the amount recovered and other litigation outcomes will vary according to the facts in individual cases. 

Call our disability support team at (888) 480-9050 or click on the button below to schedule a free consultation today!

Key takeaways on denied short term disability

1. Common Reasons for Short-Term Disability Denial:

• Lack of documentation illustrating the seriousness of symptoms
• Lack of medical records
• Pre-existing condition
• Lack of treatment 
• Misinterpretation of work-related stress as a reason for denial
• Applying for short term disability instead of parental leave 
• Your doctor doesn’t support you 
• Exaggerating or lying in your application
• Unfavourable surveillance evidence
• Diagnosis issues

2. What to do after a denial

• Appeal the Denial: You can appeal it either internally or externally. 
• Return to Work: Another option is to accept the denial at face value and return to work if possible.
• Apply for EI Sickness Benefits: If you short term disability get denied and you can’t return to work, consider applying for Employment Insurance (EI) Sickness benefits.
• Apply for Long-Term Disability Benefits: You can also apply for long-term disability benefits if your claim gets denied.
• Appeal Long-Term Disability Denial: Request a review of the denial, but success is unlikely without new and significant information.
• File a Lawsuit: You can also file a lawsuit against the insurance company. If you decide to go this route, we recommend consulting with a disability lawyer. 

3. Seeking Legal Assistance:

• Hiring a disability lawyer can provide guidance and increase the chances of a successful appeal or lawsuit.
• Consider legal representation, especially when facing complex denial reasons or when navigating an external appeal.
• Resolute Legal offers assistance with short and long-term disability claims, CPP Disability, workers compensation, and employment disputes. G

Get Your Free Book 

Click the image below to download our free book — A Beginner’s Guide to Disability Insurance Claims in Canada. 

FAQs