A Successful Disability Insurance Claim Begins with the Application for Benefits
Mindy Chmielarz
Applying for disability insurance benefits as well as maintaining those benefits requires an understanding of both the policy's terms and the tactics and review procedures utilized by the different insurance companies throughout the duration of the disability claim. During the application process, many insureds are surprised to learn that having a significant medical condition and statements from their own physician(s) certifying disability are not considered sufficient proof of claim. Additionally, from the onset of the claim and throughout the ongoing evaluation process, adjusters often manipulate the information received by the insured and his or her doctor in an attempt to secure a claim's denial or set the claim up for denial at some point in the future. The following case is typical of the delays and difficulties experienced by many of our clients who applied for disability benefits on their own.
Conveying whot seems like basic information (i.e., the duties of a chiropractor) can cause problems if not described with adequate detail because the claims analyst will simplify those duties and rely on his or her own assumptions.99
Dr. Jones had back pain for the past few years, but continued working as a chiropractor, hoping that the pain would eventually diminish or resolve. Unfortunately, his pain continued to worsen and his daily office routine further aggravated the condition. Despite many months of conservative treatment, including medication, physical therapy, and even trigger point injections, he found his ability to perform the duties of a chiropractor more and
more difficult. Realizing that his limitations had made him a detriment not only to his own health but also to that of his patients, he decided to stop working and apply for disability benefits. Dr. Jones had the support of his treating physician and felt quite confident that his disability insurance carrier would review the medical records, understand the duties of his occupation, and pay benefits in a timely manner.
According to Dr. Jones's disability insurance policy, "disability benefits will be paid if due to Sickness or Injury the Insured is unable to perform the material and substantial duties of his Own Occupation." "Own Occupation" is defined as "the Insured's occupation at the time of Disability." Dr. Jones contacted his carrier, and after answering numerous questions from an insurance company representative, he requested an application for benefits. Like many of our clients, Dr. Jones did not realize that the information conveyed duringthat initial phone call as well as on the application is an integral part of the claim and often used to delay payment or, when possible, deny the claim. Typically, the initial telephone call is used to "box" the insured into certain parameters and admissions, making it difficult for the insured to clarify or correct the adjuster's understanding of what was communicated. Following the initial call, the claims representative made numerous followup calls to Dr. Jones for "clarification" purposes and sent unending requests for medical, financial, personal, and occupational information.
After six months of nonstop demands for information (some of which were irrelevant and unnecessary), challenges to his claim, and numerous phone calls by the carrier, Dr. Jones contacted our firm. We were able to get him on claim and secure his back benefits within a couple of weeks. Flowever, if Dr. Jones had understood the application process better and/or employed us from the beginning, he could have avoided many headaches and secured his benefits much quicker.
Conveying what seems like basic information (i.e., the duties of a chiropractor) can cause problems if not described with adequate detail because the claims analyst will simplify those duties and rely on his or her own assumptions. It is also vital to provide evidence that those duties actually were performed and confirm that the insured was a hands-on, practicing chiropractor at the time of disability. Additional documentation showing proof of earnings and the status of your business may also need to be provided. This information, in conjunction with the medical records and claim forms completed by the insured's treating physician(s), is closely scrutinized
“Completing the application for disability insurance benefits is a confusing and time-consuming process. ”
by the carrier in an effort to confirm (or deny) your disability. It should be noted that the insured is not necessarily required to provide the carrier with every piece of requested information. The insured may also be asked to undergo an independent medical examination (IME), specifically an examination with a physician of the insurance company's choosing who has been hired to render an opinion regarding the insured's limitations and ability to work in his or her own occupation. Not surprisingly, IME doctors are not truly independent, and thus steps can be taken to ensure that the exam is as fair as possible.
Completingthe application for disability insurance benefits is a confusing and time-consuming process. However, it may be the most important part of the claim for benefits. Claims analysts rely heavily on the information and documents submitted with the application, as well as upon the insured's verbal responses to their many questions. Thus, in order to reduce the time taken by an insurance company to evaluate the claim and to improve the chances of a favorable determination, it is imperative that the application is completed properly and that the claim is supported sufficiently. With the proper understanding of the claims procedures, the application process can be fairly smooth and uneventful. If you are considering applying for disability benefits, have already submitted an application for benefits, or your claim for disability benefits has been denied, please feel free to contact our law firm for a free consultation regarding your claim for disability benefits.
Ms. Chmielarz, a founding partner of Disability Insurance Law Group, has extensive experience representing individuals nationwide in their claims for private and group disability insurance, long-term care and life insurance benefits. She has practiced in state and federal courts representing both individuals and insurance companies. As a partner at Disability Insurance Law Group, Ms. Chmielarz now focuses solely on the vigorous representation of insureds in their claims for disability, life, and long-term care insurance benefits.
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