Disability Insurance Claim Advice

Calling in a Disability Expert

NATIONAL UNDERWRITER  November 16, 2009, Life & Health Edition
By Arthur L. Fries, RHU

Imagine yourself going into a battle with a firecracker as your chief weapon and being confronted by an opponent with a hydrogen bomb at their disposal. Or, going to trial without the benefit of an attorney.

In today’s disability claim environment the typical scenario is that of David (the policyholder claimant) going up against GOLIATH (the insurance company). To create a more equitable balance, a disability claim consultant can offer assistance in the way of advice. This includes how the claim forms should be completed and helps to present your client’s claim in a clear and concise fashion to the insurer.

In addition, there are issues related to how your clients conduct themselves in communicating their disability to their physician, how to handle a field claims representative and how to conduct themselves should the insurer request an I.M.E. (independent medical evaluation) or F.C.E. (functional capacity evaluation).
Your client may think he has a residual (partial) claim from an emotional standpoint but in reality has a total disability claim from a contractual standpoint. There are issues related to objective symptoms vs. subjective symptoms. As an example, the claimant told the physician he felt nauseous. That’s subjective. If he then “threw up” in front of the physician that would be objective! Some claims may lean very strongly toward subjective symptoms yet be quite disabling in terms of doing the material duties of the job.

How would your client handle a request by the insurance company that he see a rehabilitation specialist when the contract provides a “your occupation” definition?

In past years, disability claim forms asked limited questions and insurance companies paid claims in a rather routine fashion. Because of mounting losses, many insurance carriers have made major adjustments in their claim departments. In addition, they utilize the services of C.P.A.s, psychiatrists, physicians with specific backgrounds, field investigators, video surveillance and other investigative agencies to analyze the claim to a finite degree.

Today, many claims are being denied because “going it alone” leaves the policyholder (claimant) at a serious disadvantage. Although you may think you, as a producer, know a lot about disability insurance, you may not be equipped to provide advice in terms of the knowledge and effort required on your part.
If your client has his claim terminated and it appears the claim is justified…what are his options? Should he remain in the corner with his thumb in his mouth in the fetal position or should he have available the services of a disability claim consultant? Should he seek the services of an attorney? Why or why not? Since we are often talking about a potential payout in the millions of dollars, shouldn’t your client have available a person to protect that money well? Do you want your client to collect on a fraudulent claim? Obviously, the answer is no. Insurers have every right to investigate a claim. But do they have the right to intimidate your client? Do they have the right to continuously ask for more information to the point where your client feels like a dog running around in circles chasing its “tail?”

The days of your client completing one or two pieces of paper are long gone. A half dozen or more forms may be required and an inadvertent or improper response by your client, his attending physician or employer can prejudice your client’s rights with a denial being the result.

Might issues relating to the insurer’s “rating” or the ire of their stockholders have a bearing on your client’s disability claim? If the insurance company sold their block of disability claims to another insurance carrier with major claim management capabilities, would that have an effect on the claim?

As you can see, there are many issues and questions that need to be addressed in connection with a disability claim. In recommending a disability claim consultant, the certain qualifications should be considered (see chart).

If the consultant can answer yes to all or most of these questions, this may be the person to get involved with. Any fee the consultant charges will be worth the advantage of having an expert at your client’s side.

Although “Goliath” might outweigh you or your client, a smart approach and strategy can bring “Goliath” to his knees. There is a war out there as it relates to a disability claim. If you believe the saying “I’m from the IRS and I’m here to help you,” you’ll believe the disability carrier has your client’s best interest at heart!

Qualifications For a Disability Claim Consultant

• What Insurance Companies Don't Want You to Know
• Why You Need a Disability Consultant
• How to Select an Expert Witness