Why are Mental Health Disability Claims Denied?

  Posted by   Rupa Karyampudi  , Partner,   MK Disability Lawyers  Posted by Rupa Karyampudi , Partner,  MK Disability Lawyers

A large proportion of disability cases we see at MK Disability Lawyers is due to mental illness. We have helped clients suffering from a range of mental health conditions including depression, anxiety, bipolar disorder, post-traumatic stress disorder, panic disorder, social phobia, addictions, and many others.

According to the Centre for Addiction and Mental Health (CAMH),  mental illness is a leading cause of disability in Canada. In any given week, at least 500,000 employed Canadians are unable to work due to mental health problems and these numbers are expected to increase.

Unfortunately, many disability claims resulting from mental illness are denied by insurance companies. There are many reasons for this. Mental illness is an “invisible” disability, which means that it is often not obvious when someone is suffering from mental illness. Further,  there continues to be a stigma associated with mental illness, which causes people to hide the illness from family, friends, co-workers, and sometimes even health care professionals.

In this blog article, I am going to explore the main reasons why mental health disability claims get denied and how you can help your case.

Insufficient Medical Evidence

One of the main reasons why insurance companies deny claims for mental illness is due to “insufficient medical evidence.” This goes back to the issue of mental illness being an “invisible” disability. There are no imaging or diagnostic tests to prove your illness. The way to make your “invisible” disability “visible” to the insurance company is through documentation in medical records.

You may be honest and forthcoming with your insurance company by reporting all your symptoms, but this is not enough evidence to prove your disability. In the eyes of the insurance company, your symptoms do not exist unless they are documented in your doctor’s clinical notes and records. It is very important that your doctors and treatment providers thoroughly document your condition and treatment. This might include writing a detailed letter to insurance company detailing your symptoms, restrictions and limitations, and your treatment.

Sometimes there is insufficient medical evidence because the claimant had not received appropriate treatment. If you are not receiving regular treatment, you will have an insufficient documentary record of your condition.

Not Receiving Appropriate Treatment

It is important to receive ongoing treatment to maintain a documentary record of your condition. More importantly, most disability policies contain provisions stating that the insurance company can deny or terminate your claim if you are not receiving appropriate treatment.

Mental illness is a treatable condition and so you must be actively engaged in treatment to show the insurance company that you are trying your best to get better. This includes seeing a physician on a regular basis. “Physician” is often a defined term under the disability policy and means a medical doctor. “Physicians” do not include naturopathic doctors or nurse practitioners under most policies. You must be seeing either your family doctor or a psychiatrist on a regular basis. Regular basis typically means on a bi-weekly or monthly basis. This is important to maintain the documentary evidence of your condition and also to make sure that a physician is carefully monitoring your medications.

The insurance company may deny your claim if you have not seen a psychiatrist. Psychiatrists are specialists in treating mental illness. At a bare minimum, you should see a psychiatrist for a consult to confirm your family doctor’s diagnosis and to make sure you are getting appropriate treatment for your condition. You should speak with your family doctor to get a referral to a psychiatrist at the earliest as there are often long waiting lists.

Most treatment plans for mental illness consist of medication and psychological therapy. Some clients do not want to take medication. This will raise a red-flag for an insurance company. If your doctor suggests medication for your condition, you must try the medication. If you do not follow your doctor’s recommendations the insurance company will likely terminate your benefits. Clients often tell us that they had an adverse reaction to medication and that is why they do not want to try medication. You must discuss this with your doctor and try any alternatives proposed by your doctor.

Another common reason why many people are denied benefits is because they are not attending therapy with a psychologist. Some clients do not want to attend therapy for a variety of reasons. If any of your doctors recommend that you see a psychologist, then you must see one if you want to receive disability benefits. If you cannot afford a private psychologist, you should speak with your doctor about getting on a waiting list for treatment at a hospital or mental health outpatient centre.

Other Reasons for Denying your Claim

Insufficient medical evidence and failure to get appropriate treatment are the two main reasons why mental illness disability claims get denied. Sometimes even if you have submitted sufficient medical evidence and are receiving appropriate treatment, the insurance company will still deny your claim for other reasons.

The insurance company may focus on workplace issues and deny your claim on the basis that your condition is due to a toxic work environment or interpersonal issues with co-workers. The medical records will have to show that you are unable to work in your own occupation with any employer (not just with your current employer).

If you were already suffering from mental illness before going off work, the insurance company may say that there is no evidence to show that your condition had changed or gotten worse and so you should still be able to work. In this case, the medical records should show an exacerbation of your condition to a degree that you are no longer able to perform your job duties.


Disability claims due to mental illness are increasing in number, however, they are also the type of claims that are often denied or terminated by the insurance company. The most common reasons these claims get denied are because there is insufficient medical evidence and because claimants fail to get appropriate treatment.

Below are the top 5 tips to help your claim for disability due to mental illness:

  1. Ensure that your doctors and treatment providers thoroughly document your condition and treatment;
  2. Make sure to see a medical doctor (either family doctor or psychiatrist) on a bi-weekly or monthly basis;
  3. Get your family doctor to refer you to a psychiatrist for a consult;
  4. If your doctor suggests medication for your condition, you must try the medication;
  5. If your doctor recommends that you see a psychologist, you must get psychological therapy.

If you are disabled due to mental illness and If your claim has been denied or terminated, or if you suspect that the insurance company is preparing to terminate your disability benefits, it is critical that you contact a lawyer specializing in disability litigation.

MK Disability Lawyers has over 20 years experience between its two partners, litigating long-term disability claims. We provide expert, personalized legal representation to disabled clients whose claims were denied for any number of reasons at any stage in a claim, including mental illness claims.  Please contact us at info@MKDisabilityLaweyers.com  if you have any questions or to request a free consultation

The preceding is not intended to be legal advice.  This blog is available for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice.  By using this blog, you understand that there is no solicitor-client relationship between you and the blog publisher.  The blog should not be used as a substitute for competent legal advice from a licensed lawyer in your jurisdiction.  If your disability claim has been denied and you need legal advice, contact a lawyer specializing in disability law. 

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