Those who become unable to work and file a claim often face rejection – frequently despite a clear medical diagnosis. Rogert & Ulbrich represent policyholders nationwide against their disability insurance companies. We are familiar with the five common grounds for rejection that shape almost every case in practice, and we show what really matters in a dispute with the insurer.

Why disability insurance companies so often reject claims

Disability insurance is supposed to kick in if you are permanently unable to perform your job at least 50 percent of the time due to illness, accident, or physical decline. In theory, a clear promise. In practice, many initial applications end with a rejection letter.

The reason is rarely an unclear diagnosis. Insurers examine claims based on narrowly defined criteria: the specific job description, the degree of impairment, the quality of medical documentation, any potential referral to other occupations, and the information provided at the time of contract signing. Each of these criteria is a potential weak point. Those unaware of them unknowingly play into the insurer's hands.

Attorney Dario Kovac, who specializes in insurance law at our firm, is familiar with this dynamic from his previous work on the insurer's side. This insider perspective is a crucial advantage in correspondence with insurance companies – because it reveals precisely where a letter is truly vulnerable to challenge and where it is not.

Have you received a rejection or a hearing notice regarding your appeal? Don't wait; have the insurer's reasoning reviewed before responding.

Reason 1: Job description not sufficiently explained

Insurers most frequently focus their claims not on the illness itself, but on the insured's occupation. The benchmark is the occupation last performed while healthy – specifically, the occupation as it was actually carried out, not as it appears in a job advertisement. Anyone who only states their job title on the claim form – "nursing professional," "IT consultant," "construction manager" – gives the insurer free rein in its assessment.

The insurer then works with standard job descriptions. From these, an alleged "residual capacity" can almost always be constructed, because the actual job requirements – physical strain, travel, shift work, screen time, lifting loads, stress levels, responsibility for employees or machines – are missing from the application.

What must be evident in the application:

• Specific tasks of a typical workdayWhich tasks, in what order, and for how long?
• Physical and mental demandsLifting, standing, concentration, screen work, patient contact, responsibility.
• proportion of individual activitiesWhat tasks characterize the profession and what proportion of the time is spent on them?
• Specific features of the particular positionShifts, on-call duty, travel, noise, heat, altitude.
• connection to the diseaseWhich of these activities are no longer possible or only possible to a limited extent due to the health impairment?

Courts now explicitly require this "defining job description." A generic application form is usually the worst option – even if the insurer sent it out exactly as it was.

Before you fill out the questionnaire about your occupation, you should know which formulations strengthen your position and which ones actually enable the insurer to make a referral.

Reason 2: Disability rating of 50 percent allegedly not reached

Insurance policies typically link benefits to a minimum 50 percent occupational disability. This threshold is the second major lever. It is frequently misunderstood – and insurers exploit precisely this.

The degree of disability is not determined by "50 percent illness" or "half work capacity," but rather by whether the activities essential to the specific profession are no longer possible to at least 50 percent. The benchmark is the occupational impact of the illness, not the illness itself.

Typical arguments from the insurer at this point:

• Performance reduction too smallThe illness only reduces performance by 30 or 40 percent.
• Adaptation instead of surrenderThe insured person could continue to practice their profession "with adjustments".
• Certificates regarding general mattersThe medical statements contained no specific reference to the activity.
• Partial load is sufficientA workload of just a few hours per day is sufficient for practicing the profession.

This argument can be refuted – but only if the job description is precise and the medical reports refer specifically to these activities. Important: A degree of disability (GdB) determined by the social welfare office does not, in itself, prove occupational disability. GdB and the degree of occupational disability are two different criteria and are frequently confused.

If the insurer doubts the degree of disability, the connection between occupation and medical diagnosis is crucial. Before submitting your next statement, ensure both points are legally aligned.

Reason 3: Insufficient medical evidence

Even when the illness is clear, the application often fails due to the form of the medical documentation. Insurers require not only diagnoses but also a functional description: What physical or mental impairment leads to what specific inability to work, to what extent, and with what prognosis?

The standard general practitioner's certificate usually does not meet these requirements. Keywords such as "herniated disc", "depressive episode" or "long COVID" are not sufficient from the insurer's point of view to prove a 50 percent occupational disability.

Insurers subsequently request their own expert opinions. These experts are commissioned and paid by the insurer. This does not automatically make them unprofessional – but experience shows that many insurers' expert opinions tend to emphasize residual capacity rather than limitations.

What a sound medical opinion must provide:

• Relation to the specific activity: Statements about specific professional activities, not just about abstract burdens.
• forecast: Expected duration and course of the restriction.
• Differentiated restrictions: Separation between physical, cognitive and psychological impairments.
• Resilience throughout the day: Consideration of daily form, pain breakthroughs and resilience over a whole working day.

Anyone who receives an insurance company's assessment should not accept it. A targeted statement from the treating physicians or a private expert opinion can pinpoint weaknesses precisely – this is often the only objectively effective response.

An insurance company's assessment is not a neutral judgment. Have it reviewed before accepting a decision based on it.

Reason 4: Referral, residual skills and reorganization

The fourth lever is the referral argument. Put simply: The insurer claims that the insured can no longer perform their original profession, but can perform another job or a reorganized version of their previous profession. Therefore, they argue, there is no occupational disability as defined in the contract.

The matter involves three scenarios that are treated differently under the law:

• Abstract referenceThe insurer specifies another activity that the insured could perform, but does not actually perform. This clause is primarily found in older contracts and has been largely eliminated in modern policies in favor of the insured.
• Specific referenceIf the insured person is already engaged in another activity, then it depends on whether this activity corresponds to their previous standard of living – i.e., income, qualifications, and social standing.
• reorganizationThis applies particularly to self-employed individuals. The insurer demands that the insured restructure their business so that the healthy aspects of the activity predominate. This is only permissible within narrow limits and only if the reorganization is reasonable and economically viable.

A referral to another job is not automatically permissible simply because the insurer claims it is. In practice, it often fails because the suggested alternative occupation is incompatible with the insured's previous standard of living, cannot be performed for health reasons, or is not realistically available on the job market. Which referral clause applies in a specific contract depends on the agreed terms and conditions – general statements are unhelpful.

Before you accept the argument for referral, have it measured against your specific contract and your specific job description.

Reason 5: Allegedly false health information provided at the time of contract conclusion

The fifth reason for rejection often only surfaces after the application has been submitted – sometimes years after the contract was signed. The insurer accuses the insured of having concealed or misrepresented pre-existing health conditions when taking out the insurance. This is called a "breach of pre-contractual duty of disclosure" and is the legal basis for two possible reactions by the insurer: rescission of the contract or contestation due to fraudulent misrepresentation.

Both have the same economic consequence – the service is refused – but differ in their requirements:

• resignationIn principle, a breach of duty by the insured is sufficient. However, the insurer must have asked specific questions, and the right of withdrawal is subject to a time limit.
• Challenge due to fraudulent misrepresentationThe insurer must prove fraudulent intent – that is, deliberate intent to deceive. The threshold is high, but in practice insurers succeed more often than policyholders suspect.

The decisive factor is not whether a pre-existing condition was "documented somewhere," but whether the insurer specifically asked about it and whether the answer was objectively false. Spontaneous colds, individual doctor's visits, or findings that the insured could not have been aware of do not need to be disclosed.

Anyone who receives a letter requesting a hearing or a notice of withdrawal or contestation should have it reviewed before making a statement to determine the exact question asked, the applicable deadline, and whether the insurer is still entitled to withdraw or contest the contract. Any ill-considered confirmation weakens any subsequent defense.

Do not respond spontaneously to a hearing notice regarding a breach of reporting obligations. Have the letter legally reviewed before submitting any written response.

Rogert & Ulbrich – Your lawyers in insurance law

Rogert & Ulbrich represent policyholders nationwide in disputes with their disability insurance companies. The insurance law practice group is headed by attorney Dario Kovac, who, from his previous work on the insurance side, has firsthand knowledge of the industry's review and rejection strategies. We examine this insider perspective in every single case – not as theory, but as concrete arguments against the letter you are holding.

We review letters of rejection, hearing, and appeal; formulate statements regarding the work performed and findings; evaluate insurance company reports; negotiate ongoing benefits and settlements; and, if necessary, represent you in the disability insurance claim before the competent regional court. We do this both out of court and in court – with a clear strategy from the very first letter.

Have you received a rejection notice from your disability insurance provider, a letter requesting a hearing, or a notice of contestation? Get in touch and secure your rights.

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