Disability Insurance Claims
Many different kinds of disability insurance policies exist, and there are many different ways in which insurance companies attempt to deny disability claims. Of course, not every kind of policy or claim denial can be discussed on this website, so we encourage you to give us a call to discuss anything and everything pertaining to disability insurance. That said, however, here are a few examples of the many things one must keep in mind when it comes to disability insurance.
Disability insurance policies are often laced with “total” versus “residual” disability language. A “total” disability typically entitles the policyholder to the policy’s maximum monthly benefit, whereas a “residual” disability typically entitles the policyholder to a percentage of the policy’s maximum monthly benefit. If the disability carrier has not denied the claim, disability carriers commonly strive to label disabled policyholders as “residually” disabled so as to lower claim payout. One must also keep an eye out for disability carriers attempting to reduce the duration of benefits. Some policies afford benefits for life, whereas other policies afford benefits up to a certain age (usually 65). Disability carriers commonly try to lay a foundation early on in the claim process for cutting benefits off at age 65. The Merlin Law Group’s disability insurance attorneys are skilled in navigating such landmines.
Some disability policies cover more than lost income. Some disability policies, for example, cover business overhead expense. This coverage is generally designed to reimburse business owners for existing overhead expenses while the owner is disabled. And this design, of course, is to keep the business afloat while an owner recovers. The Merlin Law Group aims to maximize recovery under all available coverages, not just the more common coverages.
Getting the insurance company to approve a claim in the first place is often an arduous task requiring legal expertise. You will likely, for example, have to navigate claimant statement forms, attending physician statement forms, independent medical examinations, surveillance, recorded statements, field interviews, and myriad document requests. Most of these insurance company requests are aimed at laying a foundation for claim denial, so you must take great caution during the claim investigation process to do and say the right things. Having been down the claim investigation road on countless occasions, the Merlin Law Group can guide you in a way that maximizes the likelihood of claim approval without litigation.
Once your claim is approved, that is not the end of things. The insurance company will continue to monitor your disability via surveillance, continuing claimant statement forms, attending physician statement forms, periodic medical examinations, and more. The insurance company’s monitoring will wane over time, but most companies generally keep a very close eye on you for the first eighteen to twenty-four months after claim approval. The Merlin Law Group has been down this post- claim approval road on countless occasions and can guide you in a way that maximizes the likelihood of keeping your claim approved without litigation.
Disability and life insurance policies are often intertwined to a certain extent. Sometimes a disability claimant’s life insurance policy can remain in effect without the claimant’s having to pay premium, but that fringe benefit disappears the moment the insurance company decides you are no longer eligible to receive disability benefits. Life insurance premium waiver can be easily forgotten or overlooked in pursuit of disability benefit reinstatement. The Merlin Law Group keeps its eyes on the periphery as well as the straightaway, so as to ensure you are receiving all that you are contractually entitled to receive.
Combating Carrier Delay
All too often, potential clients find themselves dealing with insurance company foot dragging. The most common example of foot dragging is the insurance company’s taking an inordinate amount of time to provide the policyholder with the most simple of documents, the policy. Well, what to do about that? No need for me to reinvent the wheel … here is an article entitled Claim Delay 101 that I published in December 2013:
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Noteworthy California Disability Insurance Decision Regarding The Regulatory Duties Of
Departments Of Insurance / Insurance Commissioners
There once was a California disability claimant named Cassaundra Ellena whose Standard Insurance Company disability claim was denied as a result of the policy’s “any occupation” / “own occupation” language.1 Eventually, Ms. Ellena took issue with the California Department of Insurance regarding such language.
What Law Governs? ERISA Or Not?
Generally, if you are part of a group health insurance plan, disability insurance plan, or life insurance plan, your claim (and related litigation) will be governed by the federal body of law called ERISA (Employee Retirement Income Security Act). In my opinion, ERISA is pro-carrier in most jurisdictions. So, in my opinion, you should try to avoid ERISA like the plague.
What Your Disability Claim File Should Include
A disability claimant’s maintaining a thorough claim file will greatly assist a policyholder attorney in unraveling a claim denial. Here are some examples of steps that disability claimants should take toward laying a good foundation for policyholder attorneys like me.
Notes To Selves Regarding The Denial Of The Rolling Stones’
I am not privy to the policy language underlying the Rolling Stones’ claim, so I cannot opine as to the (im)propriety of the carrier’s claim decision. But the above article inspired me to point out a few things to life and disability insurance claimants / policyholders.
Is Your Disability Occupationally Disabling?
I often hear something like this from disability claimants: “I don’t get it … all of my medical providers uniformly attest that my ailments are disabling, yet the carrier is still giving me a tough time … what gives?” Well, when I look into the “what gives” part of that, I sometimes find that the carrier is grappling with the mental or physical component of the claimed disability; i.e., debating the findings and / or opinions of the policyholder’s medical providers. But, more often, I find that the carrier is grappling with how the disability compromises the insured’s ability to maintain employment.1 So, what can you do to help quell (or even preempt) the carrier’s concern that your disability does not preclude you from maintaining employment?
What To Do About The Independent Medical Examination?
In the insurance context, an Independent Medical Examination (“IME”) rears its head most often with respect to disability claims. The IME is a claim investigation tool for the insurance company, whereby the carrier is attempting to assess the claimant’s physical condition independent from a treating physician’s opinions. Many of my disability clients are quite wary of the insurance company’s IME request … not because my clients’ physical conditions are somehow illegitimate (indeed, I only represent folks with legitimate ailments), but because of the not-so-secret reality of IMEs typically being a trap. More specifically, the IME is typically an insurance company’s attempt to lay a foundation for claim denial, and the IME physicians retained by insurance companies typically know exactly what the insurance company wants him / her to write. So, what do we do about the good ol’ IME?
2014 Florida Conference On Aging
Last week, my colleague and I attended the 2014 Florida Conference On Aging in Weston, Florida. We were there, with our booth and handouts, representing the Merlin Law Group’s disability, life, health, and long-term care insurances practice.
Disability Insurance Claim Denied, Routine Care
I have observed that a common basis for disability claim denial is an insurance company claiming that you are not under the routine care of a physician appropriate for treating the kind of disability you are claiming. I personally believe this type of denial to be completely subjective, and most definitely arguable.
Own vs. Any Occupation Disability Insurance
What's the difference between own vs. any occupation disability insurance policies? In this article you will see my recommendations on which type of disability insurance policy you should be looking into purchasing. First off, a reminder, that each and every disability insurance policy has in place their very own definition of disabled. This may differ from your definition, as well as your physician’s, but the insurance company’s definition is considered ultimate.
Beware of the Ongoing Disparity Between Mental and Physical Insurance Coverages
This article is largely geared toward promoting consumer awareness. The awareness being that those requiring mental health services and / or those who are mentally disabled are still (inexplicably, in my opinion) not treated equally with those requiring physical health services and / or those who are physically disabled. You should keep this unfortunate reality in mind when securing health or disability insurance.
Regarding disability insurance and for example, it is still all too common for disability insurance policies to limit the mentally disabled to a shorter period of benefits (e.g., 24 months). Compare this to the physically disabled, who are, under most disability insurance policies, entitled to receive benefits until age 65 or through their lifetime.
Legislative "Disability" Does Not Necessarily Equal Insurance "Disability"
My disability insurance clients often ask me whether being deemed “disabled” under the Social Security Disability Benefits Reform Act, the Family Medical Leave Act, or the Americans with Disabilities Act, necessitates approval of their disability insurance claim. Because I am often asked this question, I thought it worthwhile to blog about.
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