If you’re searching for reasons short-term disability can be denied, you’re probably in the middle of a frustrating moment: you’re out of work, you filed your claim, and the insurer still said “no.” This guide is written for U.S. employees in plain English. We’ll demystify how short-term disability (STD) works, why claims get rejected, and—most importantly—what to do next so you can turn a “no” into a “yes.” Along the way, we’ll point to reputable sources and regulations. You’ll also see the exact phrase reasons short-term disability can be denied woven throughout so you can quickly match issues to solutions.
The basics
Short-term disability is wage replacement (often a percentage of your weekly pay) when you can’t work due to a non-work-related illness, injury, surgery, or pregnancy recovery. It’s usually offered as an employer benefit or as an individual policy. Typical plans have a waiting or elimination period (for example 7, 14, or 30 days) before benefits begin, and benefits may run for 6–26 weeks depending on the policy.
If your employer’s plan is governed by ERISA (most group policies are), the plan must follow federal claims-procedure rules: prompt decisions, clear denial notices, and a fair internal appeal. You generally get 180 days to appeal a denial, and the plan typically has 45 days (plus one 45-day extension if truly needed) to decide your appeal.
Some states also run public disability programs (separate from employer STD). In California and New Jersey, for example, you must submit medical certification and respond to continued-eligibility requests on time. These state systems have their own forms, deadlines, and rules.
17 common reasons short-term disability can be denied—and what to do
Below are the most frequent reasons short-term disability can be denied, paired with “key fixes” you can act on immediately.
1) Missed proof-of-loss or notice deadlines
Many policies require you to give notice quickly and send proof of loss (medical evidence and forms) within 30–90 days of stopping work. Missing these windows is a classic denial trigger.
Key fix: find the policy’s deadline section and cure any late proof with a written explanation and supporting records; ERISA plans must evaluate substantial compliance when you’ve acted diligently.
2) Not “under the regular care of a physician”
Virtually every policy requires ongoing treatment and regular visits. Gaps in care—especially early in a claim—invite denials.
Key fix: schedule consistent follow-ups, document treatment plans, and have your clinician explicitly state work restrictions, frequency of visits, and why time off is medically necessary.
3) Insufficient objective medical evidence
Adjusters look for measurable findings (imaging, labs, exam findings, formal test results) and not just symptoms.
Key fix: ask your doctor to include exam details (ROM limits, strength testing), diagnostic studies, and a functional narrative; consider a Functional Capacity Evaluation (FCE) for musculoskeletal claims.
4) Failing or refusing an Independent Medical Examination (IME)
Insurers can send you to an IME with a third-party doctor; refusing it or performing inconsistently can sink a claim.
Key fix: attend, be honest, and bring a written symptom log; ask your treating doctor to rebut inaccurate IME conclusions.
5) Social media or surveillance contradicts your limitations
Insurers may review your public posts or even conduct in-person video surveillance. Innocent moments (lifting groceries once, smiling at a party) can be misread.
Key fix: lock down privacy settings, avoid posting activity, and explain context for any surveillance clips (flare-ups after activity, rare “good days,” help you received).
6) Pre-existing condition exclusions
Many group STD/LTD policies exclude disabilities tied to conditions treated in the look-back period (often 3–6 months before coverage) if disability occurs within the first 12 months (sometimes 24) of coverage.
Key fix: verify your policy’s exact look-back and exclusion window; if your disability arises outside it—or stems from a different cause—document that difference.
7) Policy exclusions (self-harm, illegal acts, some substance-related claims)
Policies commonly exclude disabilities from self-inflicted injuries, criminal activity, or certain substance-use conditions unless you’re actively in treatment.
Key fix: show treatment engagement (e.g., rehab, counseling) and clarify that your disabling condition is independent of any excluded cause.
8) Not meeting the plan’s definition of disability
Some plans use “own occupation” early (can’t perform your specific job), then later switch to “any occupation” (can’t perform any suitable job). For STD, the focus is usually your own job, but wording matters.
Key fix: map your job’s physical/cognitive duties to precise limitations from medical evidence.
9) Elimination (waiting) period not satisfied
If you return to work intermittently or don’t stay out through the elimination period, the claim can be denied.
Key fix: ask your HR or the insurer to confirm exactly how partial days, intermittent leave, or “trial returns” affect the elimination clock.
10) “Administrative” shortfalls—missing forms, wrong boxes, mix-ups
Denied claims often come down to missing employer statements, inconsistent job descriptions, or physicians leaving the “work restrictions” question blank. Key fix: request the entire claims file and denial rationale in writing (ERISA gives you that right), then fill every gap with updated forms and clarifying letters.
11) Poor documentation of functional limits
Medical notes that simply say “off work—follow up in 4 weeks” aren’t persuasive.
Key fix: ask your provider to quantify lifting limits, sitting/standing tolerances, fine motor limits, break frequency, symptom variability, and medication side effects—tie each to job tasks. Consider an FCE if musculoskeletal.
12) Lack of treatment adherence
Insurers look for consistent care and evidence you’re following recommended therapy.
Key fix: explain any gaps (transportation, cost, side effects) and document alternative medically appropriate care paths you are following. Some plans explicitly condition extended STD on proof of treatment.
13) Conflicting medical opinions (treaters vs. file reviewers)
Carriers often rely on in-house nurses or outside reviewers who never examine you.
Key fix: obtain a supportive narrative from your treating specialist addressing the reviewer’s critiques point-by-point and emphasizing exam findings and diagnostics. Consider an expert vocational report.
14) Incompatibility with state program rules (CA/NJ/NY/RI/HI)
State disability programs (like CA SDI or NJ TDI) have their own medical-certification and continued-eligibility procedures. Miss a form (e.g., California’s continued eligibility DE 2593) and your benefits pause.
Key fix: calendar state deadlines and coordinate your doctor’s online certification.
15) Income offsets or “double dipping” misunderstandings
Group policies sometimes reduce benefits for other income sources. If the math is misunderstood, you may see a “zero” benefit and think it’s a denial.
Key fix: review the plan’s “deductible sources of income” and request a benefit calculation worksheet.
16) Your job description understates the real demands
If HR provides a generic desk-job description while your actual role is physically or cognitively heavier, the insurer may conclude you can work.
Key fix: submit your own detailed duty list and ask your manager to sign it; attach photos or schedules showing true demands. (ERISA’s rules require fair consideration of the occupation’s actual duties.)
17) Incomplete appeal—evidence not fully loaded into the record
Under ERISA, courts usually review only the administrative record you built during the appeal. If you don’t include everything, you’re stuck later.
Key fix: during your 180-day appeal window, load the record with all medical, vocational, and witness evidence; the plan must issue a reasoned written decision within the regulatory timeframe.
How to fix a denial: a step-by-step playbook
Even after learning the many reasons short-term disability can be denied, you still need a game plan. Use this step-through to organize your next moves.
Step 1: Get the denial letter and your claim file
Ask in writing for the entire claim file (every note, call log, medical review, and rule the plan used). ERISA’s claims rule requires “reasonable” procedures and access to information relevant to your claim. This lets you see—and fix—exact weaknesses noted by the insurer.
Step 2: Calendar the 180-day appeal deadline
Put the last allowable day on your calendar and plan backwards. It’s better to file one thorough appeal than rush multiple incomplete submissions. The insurer generally must decide within 45 days, with one possible 45-day extension if truly necessary.
Step 3: Fill the medical gaps
Ask your physician for a detailed narrative linking objective findings to job-specific limitations (e.g., “cannot keyboard more than 10 minutes due to ulnar neuropathy; requires 15-minute rest per hour; cannot meet production quotas”). If your condition is orthopedic or pain-related, discuss an FCE to objectively test tolerances; if it’s neurological or cognitive, include neuropsychological testing when appropriate.
Step 4: Address “consistency” issues head-on
If surveillance or social media was cited, write a short statement explaining the context (rare good day, help received, crash afterwards). Ask your doctor to corroborate the pattern of flare-ups, post-exertional malaise, or delayed-onset pain that the video doesn’t show.
Step 5: Confirm treatment adherence
When one of the reasons short-term disability can be denied is “not following treatment,” show proof: appointment logs, PT/OT attendance, medication attempts (and side effects), counseling, or specialist referrals. Where a treatment is unsafe or contraindicated, have the doctor say why in writing.
Step 6: Correct job-duty mismatches
Attach a clear duty list and ask your supervisor to verify it. If your employer’s internal description is vague, explain real-world tasks and quotas, and how your limitations conflict with those tasks on a reliable, full-time basis. (Many STD policies focus on your own job’s demands.)
Step 7: Mind the state-program rules (if applicable)
If you’re also claiming state benefits (CA SDI, NJ TDI), track those forms: initial medical certification and any continued-eligibility documents. Missing a 20-day response on CA’s DE 2593, for instance, can stop payments.
Step 8: Submit a single, comprehensive appeal package
Label exhibits, include a cover letter summarizing the medical theory of disability, and cross-reference the policy definition and each reason short-term disability can be denied that you have now fixed. Keep copies. The plan must give you a reasoned written decision within the ERISA timeframes.
How can ERISA timelines protect you (if you use them)
ERISA gives you structure: you have up to 180 days to appeal, and the plan generally has 45 days (plus one 45-day extension) to decide. Use the time to load the record—because if the appeal is later litigated, courts typically review only what’s in that record. This procedural reality is both a challenge and a powerful opportunity to fix every one of the reasons short-term disability can be denied before it ever reaches a judge.
Practical checklist (U.S. workers)
Request your complete claim file and policy.
Calendar the 180-day appeal deadline (count precisely).
List each denial reason in the letter; map a fix to each one.
Ask your doctor for an objective, duty-specific narrative; consider FCE.
Compile treatment proof and explain any adherence gaps.
Verify state-program forms (CA/NJ/NY/RI/HI) if applicable.
Tighten your online footprint; avoid new activity posts.
Submit one complete, indexed appeal with exhibits; keep copies.
FAQs
Does short-term disability require “objective” test results?
Not always—but the more objective evidence you provide (exams, studies, FCE), the stronger your case. Many plans emphasize function over diagnosis.
What if my policy mentions “waiting” or “elimination” periods?
Those are the days you must be disabled before benefits start; verify how intermittent work affects the clock.
Can an insurer send me to its doctor?
Yes, via an IME. Attend and be truthful; ask your own doctor to respond to any errors.
How long do I have to appeal?
Typically 180 days under ERISA; then the plan usually has 45 days (plus one extension) to decide the appeal.
A final word
When you first read a denial, it’s easy to feel defeated. But most reasons short-term disability can be denied are fixable with targeted evidence and careful procedure. If you’re overwhelmed, consider consulting an experienced ERISA disability attorney or a reputable workers’-side clinic. In the meantime, keep your treatment steady, your documentation detailed, and your appeal organized. The mix of objective proof, clear job-task mapping, and on-time procedures is often what turns a denial into an approval.
