Disability Insurance Claim Advice
Murder by Proxy: Death of a Disability Claim
Dental Economics, December, 1998
By Art Fries
In today's disability-claim environment, an insurance company doesn't have to commit physical murder to accomplish its goals. Instead, the company creates an atmosphere in which the policyholder (claimant) is reduced to economic and/or emotional suicide. When pushed to the extreme, paresthesia sets in and the claimant resembles a jellyfish, floating in a sea of vast darkness
Not all insurance companies are guilty as charged. Some, actually, by their actions, make an effort to be honorable and treat their insureds with respect. Those I applaud; but their numbers are few and far between these days. In my capacity as a disability-claim consultant (mostly to physicians, dentists, and attorneys), I'm on the front line, doing battle on behalf of my clients. Most of the time, my enemies don't know about my existence because I don't surface from behind my bunker. But, my enemies know I'm out there. When and if I do surface, I'm a warrior prepared to do battle with all the weapons necessary to win the war ... and war it is!
I despise war! I don't like guns. I don't like to fight. But when Goliath is trying to step on me as if I were a lowly ant, I will summon on all my energies to get out of the way of his murderous heel. Then, I will fight back with all the weapons of the disability war at my disposal.
But first things first. To be able to win the disability-claim war, you first must be prepared for the enemy's tactics. What are the insurance companies' "weapons" and how do they deploy them? The arsenal is listed in the accompanying article.
What are your weapons? The best possible weapons that you can possess are your integrity and your credibility. Add to that an individual who can guide you through every step of the claim process to help you get past the "land mines" for physical and mental pain when you are in need. You want someone to lean on when you feel you no longer can stand up to the Goliath of a large, insulated, multibillion dollar, faceless corporation that wants to murder you by proxy.
Whether you have a new problem or a terminated claim, a disability claim consultant can provide help in areas where you do not have expertise. A consultant also can help you provide clarification of issues related to your claim. In the worst-case scenario, the consultant can provide backup or recommend an attorney with experience in dealing with disability claims should legal recourse be necessary.
"Shooting from the hip" was not the way you were taught to practice your professions. Preparation, preparation, preparation is what gives you the confidence to achieve success. The same can be said for fighting the disability-claims wars. You must use all of the weapons at your disposal to win. . . and that might include some added ammunition in the form of help and guidance from a disability-claim consultant!
Video surveillance: Insurance companies will videotape you to create a scenario of embarrassment and to use as a threat against you. Even with your bad, low and/or cervical problem you rightly feel a need to get out of your jellyfish position and to get some exercise. You play golf, and, even your doctor will tell you the exercise is good for you. If the pain comes back or gets worse, you walk off the golf course and go back another time. When you are performing surgery or doing a root canal on a patient and the pain comes on or exasperates your symptoms, you can't walk away from that activity so easily. So you finish up the procedure, knowing that you came close to committing malpractice.
Paperwork: The amount and depth of the forms that you are requested to complete is overwhelming. Some of the questions asked on these forms include:
- How did you spend your day in the past (prior to disability)?
- How do you spend your day now?
- Describe your disability detail.
The questions go on and on. . . like the constant flow of the ocean waves. God forbid you make a mistake in your answers. . . a sure way to have your claim denied!
Then there are the requests for copies of your corporate and personal and tax returns for the past five years, for copies of your patient calendar for the past six or 12 months, etc. it seems like a never ending trail of paper. . . and the insurance company just keeps coming back for more.
Investigation: Insurance company representatives call you on the telephone to ask more questions. People come to see you either unannounced or by appointment, asking still more questions. Sometimes, an insurance company representative will ask you to sign a statement that all the facts related to your claim have been compiled at the meeting. do you sign, do you weep. . . or do you say no to signing the statement?
Even after you have sent in all the financials, they may be scrutinized by a CPA representative, hired by the insurance company to make sure you and/or your accountant were’t too creative in computing the figures. If you have a partial (residual) claim that involves a loss of earnings, the subterfuge the insurance company creates with this ambiguous policy language (designed to further reduce your monthly benefit) will create even more anxiety on your part.
Home office physicians, nurses, rehab therapists, ergonomic people, and any one of a number of other soldiers are ready and willing to do further battle with you — to the point at which you will be ready to crawl into a corner and lie in the fetal position with your thumb in your mouth. The privacy and dignity that were once a part of your life will have withered away.
IME (Independent Medical Evaluation): After you provided all of the appropriate medical information — including copies of every paper and any notes that your previous and current attending physicians have in their files, they will want more because they still won’t believe you! So, they bring out the biggest weapon of all — the IME! Sometimes they produce the IME early in the battle, sometimes later; but, whenever it is introduced, it seems never-ending. Even if the biggest name doctors in the world have attested to your current disability or you have been on disability for the past five years, the IME may surface, ready to release its barrage of bullets. A more appropriate name for the individual conducting the IME might be “gunslinger” or “hired gun” . . . a person paid by the insurance company to render an opinion that will eliminate you from the claims roles.
Hopefully, your claim won’t be related to depression or stress, since that will typically involve a double whammy. . . a visit to both a psychiatrist and a psychologist. At these visits, the doctors will ask you every question possible about your life since the day you were born. From your answers, they will create a mound of paperwork you could never have imagined. IF you were depressed before you went in for the exams, just think of where you will be on the depression scale once the exams have been completed! If you ask for a copy of the completed report, you will be told that you can’t get it because you have not asked for it in the “proper way”. Of course, the insurance company won’t tell you the “proper way” until you have gone around two or three more times!
Changing of the rules: Let’s assume you were an oral surgeon when you purchased your disability policy. You sold your practice due to a cervical or low-back problem. At the time of the sale, your broker or agent told you, “You can’t do surgery, but you can do office exams related to your specialty. However, the insurance company the will say you have a partial disability, not a total disability. That means if your earnings are reduced by a certain percentage, the company will pay you some money to age 65 only — not for a lifetime! That’s assuming the company doesn’t throw in the hidden hooker of saying you have to be totally disabled first (or at least the waiting period) before it will pay you under a partial (residual) claim. In other words, what you thought was covered under your disability policy when you purchased it may not be covered at all when it comes time to pay you under a claim. These rules change, based upon interest rates, overhead expenses, insurance-rating organization opinion, the stock market, and a host of other factors that might enter into question.
The buyout: Now that the insurance company has weakened you to the point of mental exhaustion, it comes in for the kill! It is financially advantageous to the company to eliminate the reserves set up to satisfy the requirements of the insurance department of your state. So, the insurance company puts out a “feeler” to see if you will surrender your disability policy — and your claim — for a check representing 10 cents on the dollar. And that’s if the company feels there is some merit to your claim! If your claim isn’t deemed “perfect”, a termination letter may be more the order of the day.