Disability Insurance Claim Advice
Someone To Lend A Hand When You're Hurting
Dental Economics, May, 1997
By Art Fries
These new kids on the block, disability-claims consultants, carefully watch over the progress of filed claims.
Would you go to court without an attorney? Would you file a tax return without the help of a CPA? Would you perform surgery to amputate your leg, when a surgeon might be a more appropriate person for the job? Most of us would answer no to these questions.
But, what if you have a disability claim? Are you prepared to go up against Goliath ... the giant money machine that is ready to step on you and bury you, as if you were an ant?
Seems as if you may need help. Shazam ... enter the new kid on the block ... the disability-claims consultant. They are few in numbers, if you can find them at all. Yet, they cost no more than most other professionals who provide the type of service you so readily need and deserve. There are three areas of consideration, the third of which might help you to secure many thousands or millions of dollars, should you have a disability claim.
How do you think your disability claim will be handled? What is the reality? What might you expect a disability-claims consultant to do on your behalf?
It is possible for a consultant to be in the dark in some areas that might be brought to light by an attorney who has filed a lawsuit against the insurance carrier.
As an example, did the home office ask the proper questions and record the proper answers in the telephone interview conducted during the underwriting process? Was the person asking the questions qualified to interpret the answers?
Did the underwriter want to clear his desk when your original application for coverage was being considered? Did he not bother getting an attending physician's statement, because it was just prior to the Christmas holiday and he wanted to get the policy issued and paid for and on the books before year's end? Might an underwriting manager have requested this of all underwriters in the department to look good on the charts for that week?
Have you ever really thought about the potential payout on the part of the insurance company? The company certanainly knows, since it set up a "reserve" for the future.
Example: a 45-year-old professional with a lifetime payout and a $10,000 monthly benefit might be looking at $3.5 million or more over the next 30 years, and, in many cases, this money is tax-free! Does't this large amount of potential money warrant that you secure the best possible advice to substantiate your claim? With the insurance company now having access to experts in the areas of video surveillance, CPA'S, psychiatrists, etc., shouldn't you also be hiring an "expert" to try and level the playing field? Unfortunately, at this time, there are very few agents/brokers who can provide the in-depth advice necessary with respect to a new or terminated claim. Hopefully, this will change in time, as insurance companies active in the disability arena sharpen the blades of their guillotines and build their arsenal of hydrogen bombs in readiness to blow you away at claim time.
Bottom Line: If you are having difficulty collecting, or the insurance company is having you run around in a circle like a dog chasing its tail, you need help. If you are terminated from an existing claim, you also need help. This is a serious war, and, as previously indicated, millions of dollars might be at stake. Even after you have worked with a consultant, should your claim be denied or terminated, you might still have legal recourse through the courts. The consultant can provide copies of his/her notes and observations to an attorney of your choice, or the consultant might be able to recommend several attorneys who have experience in dealing with disability claims. Attorneys like working with consultants, since it can strengthen their case and also provide an excellent source of education and information. When you need help on a disability claim call the new kid on the block, the disability-claims consultant . . . if you can find him! Good Luck!
How do you think your disabiity claim will be handled?
You will complete and submit whatever claim forms are provided to you by the insurance company.
You will give your attending physician(s) forms to complete and return them to the insurance company.
You will expect to receive a monthly check in a timely fashion for the duration of your claim.
What is reality?
Most claimants, after completing their claim forms, will immediately and unknowingly prejudice their rights.
Most attending physicians, even with the best of intentions, also will prejudice your rights . . . and won't even know it. . Most attending physicians have never been educated about the difference between a Workers' Compensation claim response and that of an individual or group disability claim.
You may be requested to have an IME (independent medical evaluation). This type of exam might last for an hour or three or more. How should you conduct yourself at this exam? What should you bring with you? Will the examiner, hired and paid for by the insurance company, be as objective as you might wish? Will he/she be fair? Is there anything you can do when the physician conducting the exam says: "There are no objective findings"?
You may be asked to provide a list of your predisability duties and hours compared with your postdisability duties and hours. That is, what you did prior to disability and what you are doing now. This is one area that can make or break your claim.
The insurance company pays you for five months and then stops. What are your rights? What should you do? Roll over and play dead, consult a consultant, or consult an attorney?
Objective vs. subjective symptoms. Can the pain be measured or is it related to what you tell someone? Example: You tell your physician you feel nauseous. That's subjective. You throw up in front of your physician. That's objective. Do different insurance companies have different attitudes in this area? Can you do something to help your claim?
A buyout! A person representing the insurance company comes to your door, often unannounced, “dangling” a check in front of you. Should you grab the bait or just mouth it with the option of spitting it out? Should you accept this check and give up your claim, as well as your insurance policy? If you don’t accept, should you accept it in round two, in round three?
And, how much should you accept should a buyout appeal to you? Do you know what key advantage there is for the insurance company if you should accept?
What should you expect a disability-claims consultant to do?
Advise you on how to complete the claim forms, line by line, in a way that honestly and clearly presents your medical problem in the best possible light to the home office claims person. Most claim forms that I have reviewed are too vague, with respect to the answers provided, and could cause doubt in the mind of the home office claims person. You may think, from an emotional standpoint, that you have a partial (residual) disability claim, but from a contractual standpoint, you have a total disability claim. One type might bury you in paperwork every month . . . another may not.
Advise you on how to communicate with your physicians so that they know the implications of their answers on a claim form. The attending physicians always should be truthful, but we don’t want a physician to provide a response that unknowingly blows your claim out the window.
Advise you on what to expect and how to handle the IME.
Advise you on how to set up your pre- vs. post- disability duties and hours. The days of just saying you rest, watch TV, and walk the dog might just not hold up in today’s claim climate. This could make a difference between you collecting nothing, something or 100 percent of your monthly benefit.
Advise you on how to handle a “kiss-off” or termination from the insurance company. It doesn’t necessarily mean you crawl into the corner in the fetal position, with your thumb in your mouth, although emotionally that is what you may feel like doing. You may have a very legitimate claim, but your paperwork has been lacking in the way of misinformation, or information that is not clear to the claims department. Or you might have been acting in a way that would lead the insurance company to think that your were not disabled by definition, when in fact, you were. As an example, you have a major cervical problem that prevents you from doing surgery/procedures. You have intermittent pain and a protruding disc that shows up on an MRI. However, you see no problem driving your five-speed sports car and switching gears with your “operating arm”. This, in spite of the fact that you might be driving with some pain or difficulty.
This, by itself, might not cause the insurance company to terminate your claim, but this, added to several other questionable acts, might be a reason for doing so.
Advise you on subjective symptoms which can be converted to objective symptoms with the proper medical testing. And, some subjective symptoms by themselves might pose a problem with your claim, but for some types of claims, they may not.
Help you decide if a buyout can be to your benefit or detriment and what is reasonable in the way of an offer by the insurance company.
Review your disability policy(s) or a photocopy of it, including the original application for coverage. This should include a review of the original proposal, provided by the broker . . . if available. Were the questions on the original application clear or were they poorly worded? Might the agent/broker have left out any pertinent information? Might the insurance company have terminated a claim or denied it because of an omission or a mistake by the agent/broker?
The definition of total disability, partial (residual) disability, a COLA option and any one of a number of options, wording, exclusions, etc., will have a bearing on how your claim is handled.