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Disability insurance claims: 12 ways of business




By Mark F. Seltzer, Esq.

If you thought Halloween was scary, then you haven’t been through the claims process with a disability insurance company. The Companies maintain an arsenal of well-paid, well-trained professionals and claims staff who sometimes seem like they are masquerading at a holiday costume ball. The reality is that the claims process may very well become the consummate “trick or treat” experience.

Your goal in filing your claim is to obtain your disability insurance benefits, and as quickly as possible, during a period in your life when you are disabled, most vulnerable, and in financial need. Although this process will never be a sleigh ride to Grandmother’s House, it is certainly worth thanksgiving when that goal is accomplished. The problem is that, when you go through the claims process you will be like a babe in the woods, often feeling lost and unable to find your way, and all the while subject to the multitude of strategies and defenses successfully employed to gobble-up your claim.

With the fact that obligating your disability insurance company to pay you benefits is no holiday, it is important that you don’t wing it through the claims process without a leg to stand on. This article is then to provide you, the disabled physician, with a helpful guide to the “Twelve ways of business” to better understand the disability insurance claims process.

1. As I have advised you on multiple occasions in past articles, your claim starts with your policy. Understand what obligates the Company to pay you benefits. The policy also sets forth claims filing procedures and appropriate response times.

2. Prior to filing your claim, make sure that you understand the material and substantial duties of your occupation, or occupations, at the time you became disabled. Also, make sure that your treating doctors have this understanding.

3. Throughout the claims process and for the duration of your claim, keep a file of all communication between you and your Company, including copies of any forms which the Company requires you to fill out and submit. Ask your doctor to provide you with copies of any communications with your Company. Also, make sure that your doctor has carefully read, considered and answered any forms or questionnaires requested by your Company. Maintain copies of any other information submitted, including financial or otherwise.

4. Beware of the information age. Any information about you, out there in Internet space, will most probably be discovered and compiled by your Company as part of its claims file.

5. After you have raised your claim with your Company, you will receive a claims form that needs to be filled out by you and your doctor and then forwarded to your Company. After your disability insurance carrier has received the claims form, they will request additional information. It is usual for them to initially request financial documentation along with CPT codes.

6. Your Company will begin the process of assessing your occupation after reviewing this information, with an eye toward to achieving an occupational assessment most advantageous to the Company.

7. The Company will also review the medical component of your claim which you ultimately must prove rises to the level of “disabling.” The medical reviews often involve highly-skilled, forensically-trained medical experts looking to achieve a medical assessment also most advantageous to the Company. While this process begins with your treating doctor filling out an attending physician’s form, it usually does not end there. The Company most probably will additionally request other medical information which may include clinical notes or even direct conferences with your treatment providers.

8. If the Company has not received the information which it has requested, has not received the requested information in a timely fashion, or has any questions or issues regarding either the information received or any other aspect of your claim, the Company may engage in what seems to be a relentless quest to obtain never-ending amounts of information, often seemingly too burdensome to obtain. At best, these requests for information, and then information reviews by the Company, may significantly delay your receipt of benefits. At worst, you may never be able to satisfy the Company’s understanding of its proof of loss requirements in your policy or you may want to simply walk away from your claim because of the huge effort involved.

9. At some point in the claims process, and especially if the above applies, your Company may request a face-to-face meeting with one of its field representatives in order to conduct a personal interview. Most field representatives are well-trained investigators who usually have much experience dealing with policyholders claiming disabilities and in obtaining related information. The purpose of the interview is obviously for the Company to obtain more information, and first-hand, at that. It is usually the Company’s first opportunity to meet with you in person, and size you up as a claimant. This meeting is often critical to the claims process. Any and all information which you provide (or don’t provide) to the Company during the interview may be used to refute your claim. Unfortunately, the completion of the field representative meeting does not necessarily mean the end of the requests for information, the claims process, or otherwise.

10. One of the important tools at the Company’s disposal during the claims process, or afterwards, is surveillance. Within legal guidelines, this is permissible. Your Company may film or photograph you, or even attempt to interview your neighbors, business associates or other people whom it feels can provide relevant information. The likely purpose of surveillance is to develop information to refute the claim. Your Company will be looking for inconsistencies between the information you have provided for consideration and the actual activities in which you were engaged as captured on film.

11. Ultimately, and hopefully, at some point after considering all of the information submitted and obtained, your Company should come to a decision on your claim. (By the way, sometimes the Company does not make a decision on your claim). In the best case scenario, if your Company does accept liability for your disabling condition, agreeing that you have satisfied your contractual obligations under your policy, the process is still not over and will continue for the entire duration of your claim. You need to prove entitlement to your benefits every month that you are on claim. The forms, financials (if relevant), and information flow to your Company will be a continuing requirement before you get paid your benefits. And that assumes that the information submitted satisfies the Company’s proof of loss requirement and ongoing acceptance of your condition as disabling.

12. On the other hand, the worst case scenario is for your Company to deny your claim (during your time of need and despair). The biggest problem that you may very well face, during what can be a huge uphill battle against your Company, is that you will be stuck with whatever information you or your treating doctors provided to your Company during your claims process.

When you consider the importance and magnitude of the claims process, in conjunction with all the issues, defenses and strategies at play, you certainly don’t want to end up with a big nightmare. The Company will look for any skeletons in your closet in order to reap the fruits of this information. You have to sow the seeds of a successful claim in order to harvest the benefits to which you are entitled. If you become disabled, you hope to give thanks for the joy of having your disability insurance policy. Unless you believe in Santa, you better take this process seriously.

Mark F. Seltzer, Esq., is the founder of the law firm of Mark F. Seltzer and Associates, representing Physicians, Healthcare Practitioners and Professionals in disability insurance claims and cases. The firm is located in Philadelphia, Pa.


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