Disability Insurance Claim Advice
Resurrection of a Disability Claim
California Broker, March 2012
By Arthur L. Fries, RHU
This article will emphasize the importance of seeking advice of one with expertise on the subject at hand. Many years ago, a fuse needed to be replaced in my house. This was long before circuit breakers were used and a fuse box ruled the house. I attempted to remove the fuse, but it was stuck so I tried getting it out with a screwdriver and broke the fuse and it became stuck. I then attempted to take out the fuse base with pliers and my efforts were rewarded by an electrical shock that tossed me some 10 feet across the room. My ignorance was at an all time high as a result of my not turning off the master electrical switch. Having my hands shake for an hour after the incident added insult to injury and a good lesson was to be learned. When you don’t know what you are doing, call in the expert. In this case added knowledge or an electrician would have saved the day.
The above leads to my story about a dentist client who submitted a disability claim without giving any thought to his answers or his actions and, as a result, made many mistakes. I received an e-mail from him for the first time in which he indicated the following, “I submitted a disability claim, but it is not proceeding as smoothly as I’d hoped.” I called twice and my phone calls were not returned. Five months later I received another e-mail stating, “The claims process is not going as well as expected and perhaps it is time we talked on the phone.”
I again responded with an e-mail. We spoke on the telephone and, within several weeks, I was hired in a consult capacity. It was now eight months since the initial paperwork was submitted on the claim and the insurance company was indicating various reasons why they didn’t see a basis for paying the claim. It was now my job to resurrect the claim from the ashes and do my best to get the claim paid.
Clearly, my client had medical symptoms that would be the basis of either a partial or total disability claim. However, not understanding the policy language and not having in his possession his second disability policy was a mistake. The most serious mistake was not having control of the claim.
Following are the mistakes I encountered:
- Indicating on the claimant’s portion of the claim form that he was totally disabled (at the time of claim submission) when, in fact, he was partially disabled.
- Having a relative physician (in this case his father) complete the attending physician statement (APS) in spite of the fact that the contract said this was not permissible.
- Having another physician complete the APS without any guidance provided so that the completed form indicated no disability.
- Having a physical therapist complete yet another APS who did not indicate any disability (either partial or total) and did not have any basis of authority with the insurance company.
- Not reducing his hours to be eligible for partial disability (as required by one of his contracts).
- Not reducing his earnings enough to qualify for a partial disability claim.
- Indicating on the claim form that he supervised nine people when in fact he supervised nobody!
- Not being clear as to when his disability began (on the initial claim forms as well as in communication with his attending physicians).
- Not seeing the appropriate doctors or receiving appropriate care as required by policy language.
- Not keeping a copy of the claim forms or the attending physician statement that was submitted to the insurance company.
- Providing procedure code records to the insurance company, that were in excess of those required.
- Permitting his relative doctor to talk to the insurance company when there is no legal or contractual obligation for him to do so.
- Submitting continuation claim forms and APS’ that were not clear and in conflict with each other.
- Failing to understand claim department procedures.
- Not securing enough objective evidence of the multiple medical symptoms claimed.
- Not following up properly with his health care providers so that the insurance company could receive medical records in a timely fashion.
- Having no understanding of the various weapons available to an insurance company and how they affect a claim (video surveillance, field investigation, independent medical exam, functional capacity evaluation).
- Using a method to communicate with the claim department that put him at a disadvantage.
- Sending documents to the insurance company that encouraged loss or not receiving the documents.
- Acting in a cavalier fashion as one would do purchasing a container of milk at the supermarket when potential benefits involved some $2.5 million potential dollars.
The normal process time from the initial submission date until the claim department provides an answer should be anywhere from two to five months with three and a half to four months being the average. In this case with my additional help it took an additional four months or almost one year from the date of the initial submission to receive a favorable answer. In addition, the claim beginning date was moved forward in order to meet the contractual provisions of the policies. A few battles were lost, but there was a successful outcome in terms of winning the war. The client lost valuable time trying to go it alone. There are many variables related to a disability claim. Don’t make the mistake of trying to be your own expert.