You have worked hard your whole career, but now you find yourself unable to practice your profession because of a physical or mental disability. You’re not alone. In fact, some statistics indicate that a person in their mid-thirties has a 50:50 chance of experiencing a disabling condition that prevents them from working for at least three months before they retire. In addition, one out of seven workers will become disabled for a period of more than five years before reaching retirement.
Luckily, you were wise enough to purchase disability insurance to offset the risk that you would become disabled. Unfortunately, however, disability insurance companies have developed a sophisticated system to maximize profits and avoiding paying your claim, regardless of the merits of your condition. How can you avoid having your disability insurance claim denied or terminated?
Among the many hurdles you will likely face when filing a claim for disability insurance benefits are:
• Understanding, interpreting, and correctly following the terms of complex policies drafted by insurance companies;
• Recognizing, avoiding, and dealing with insurance companies’ efforts to wear out claimants by delaying the claim process;
• Ensuring that treating physicians take the time and effort to document the disability sufficiently and in a manner that is helpful to your claim;
• Avoiding insurance companies’ attempts to use out-of-context secret surveillance as a basis for terminating or denying your disability insurance claim;
• Ensuring that independent medical and psychological evaluations are conducted appropriately, fairly, and without risking injury;
• Fighting insurance companies’ attempts to terminate or deny disability insurance claims simply because the symptoms of your condition are subjective or self-reported;
• Overcoming the great number of other techniques and tools that insurance companies have developed to engineer a basis for denying legitimate disability insurance claims, because their primary goal is profit.
Complex and Confusing Insurance Policy Language
The language of every insurance policy is complex and confusing, drafted by attorneys and insurance company employees with an eye towards protecting their own interests. When denying or terminating a claim, insurance companies capitalize on the complexity of their policies at the expense of the insured. The truth is that there is no “standard” insurance policy contract, and the provisions vary dramatically from policy to policy, where coverage is usually circumscribed and restricted with different qualifying words and phrases. In order to overcome the insurance companies efforts to use jargon and legalese to avoid paying claims, it is crucial that a claimant understand the specific definitions of the key terms and phrases in the policy, and also the ambiguities in those words. When words or phrases are ambiguous or their meaning is not clear, courts will construe the meaning of those terms against the drafter (the insurance company) and in favor of the other party (the claimant). Having a thorough understanding of your policy language may be the most important step to filing your disability insurance claim.
Efforts To Delay The Claim Process
One of the most common techniques that insurance companies use to avoid paying benefits is drawing out the claims process for as long as possible. In this way, insurance companies can increase the attrition rate of claimants, such that legitimately disabled people will simply give up out of frustration. But, insurance companies have a legal obligation to make prompt decisions, and a claimant tolerate undue delays.
Working With Your Treating Physician
Perhaps the most important aspect of a successful disability claim is the medical documentation of your disability. Many physicians are extremely busy, and may not always take the time to write detailed and accurate reports of your condition. It is common for hurried physicians to simply copy-and-paste boiler-plate descriptive language into office visit notes that is actually false or inaccurate. In a rush to complete paper work, a doctor’s office visit note may include phrases that apply to most patients, but that are completely inaccurate as applied to you. For example, a doctor’s report from an office visit may say that “patient is in no apparent distress,” when in fact, the purpose of your appointment was to treat your chronic back pain that is preventing you from working.
In addition, depending on your relationship, they may not have any interest in devoting time to your disability insurance claim. But, fully discussing your condition with a compassionate treating physician is crucial to obtaining documentation of your condition that supports your claim.
Surveillance
After you file your disability insurance claim, it is very likely that you will be secretly videotaped or photographed by your insurance carrier during their investigation of your claim. If they are able to document you engaging in activities that you claimed you could not perform, they will likely use this evidence as a basis to terminate your claim. It is also not uncommon for insurance carriers to send these videos or to your treating physicians in an attempt to sour your relationship, and convince your physician to make statements that are against your interests. It is important to be on-guard against these tactics, recognizing that these out-of-context videos may be misconstrued to achieve the insurance company’s goals.
Independent Medical Examinations
Insurance companies often ask disability insurance claimants to submit to an “independent” medical examination performed by a physician chosen and paid by your insurance carrier. Obviously, this creates a conflict of interest, where the doctor evaluating your disability has an indirect incentive to improperly diagnose your condition. You may also be asked to undergo exams by someone other than a physician. All of these exams can be stressful and even painful or dangerous. It is not uncommon for portions of the exam to include protracted or intrusive diagnostic tests. Of course, the primary purpose of these exams is usually not to diagnose your condition. Rather, these exams are often just another tool insurance companies use to deny or terminate your claim. Therefore, it is important to be aware of your rights during this process.
Subjective Conditions and Self-Reported Symptoms
Perhaps the most common conditions for which insurance carriers will deny disability insurance benefits are those where the symptoms or the intensity of symptoms are subjective or not objectively measurable. For example, chronic back pain, neck pain, rheumatoid arthritis, and depression, are all conditions where the severity of the condition may be impossible to measure, other than with subjective statements from the patient, and verifiable evidence may simply be too difficult to obtain. Nonetheless, insurance companies may deny claims for a lack of verifiable evidence of the condition, capitalizing on the lack of objective evidence. In many cases, however, the terms of the insurance policy do not contain a provision that requires an insured to provide objective evidence of their disability. Thus, it is absolutely necessary for a claimant with a disabling condition where the symptoms are not objectively verifiable to understand the actual terms and provisions of their insurance contract.
Overcoming These Obstacles
The disability claim process has been designed by insurance companies to be overwhelming and exhausting. Insurers hope that by making the process difficult, many claimants will simply give up. Insurance companies know that most of those who don’t give up, will unknowingly succumb to the many tricks and traps that insurers have created to justify denying or terminating a claim. Insurers tactics are not insurmountable; however, the fight can be extremely difficult to take on alone, especially when the opponent is a billion-dollar industry devoted to reducing costs and denying claims.
*By: Edward O. Comitz, Esq.