Be Prepared When Filing or Appealing a Claim Subject to ERISA

ERISA, the Employee Retirement Income Security Act, was enacted in 1974 with the  purpose of protecting employee benefit plans, but insurance companies have become adept in using ERISA rules and regs to their advantage.  Almost all Short Term Disability (STD) and Long Term Disability (LTD) plans are subject to ERISA, as are some individual plans.  ERISA is complicated and has a number of requirements regarding disability claims that both the insured and the insurance company must follow.

Once a disability claim subject to ERISA is filed, evaluated, and denied by an insurance company, the insured either accepts the denial or files an internal appeal with the insurance company.  Each step of this process has deadlines that must be carefully followed, or you can lose all future benefits along with your right to appeal or even litigate.  It is important to keep detailed records and stay on top of your claim.

Our office recently received a referral from an insurance agent whose client’s employee had filed a disability claim under their LTD policy.  She had rheumatoid arthritis and could no longer do her job.  The employee’s disability claim had been denied, and they were about to appeal when the agent thought to contact our firm.  I am going to lay out some of the mistakes that were made or about to be made and how we were able to fix them, hopefully helping you avoid the same pitfalls.  Inadvertent mistakes can happen and can cost hundreds of thousands of dollars in past and future benefits. Continue reading

Filing a Disability Claim for Depression

When dealing with the very serious medical condition of depression, the last thing a person wants to worry about is whether or not their disability claim is going to be approved. In the past, insurance companies would accept depression claims, as they thought the few individuals diagnosed with depression would only be on claim for a short while and then return back to work.

As time has progressed, this acceptance is no longer the case. Depression has become a more common diagnosis and resulted in longer, and more expensive, disability claims for the insurance companies. When an individual deals with  depression, there are many issues that can arise.  It can be difficult to get a clinical diagnosis of depression, as the testing can be more subjective rather than objective, such as for paranoid schizophrenia or seizure disorders.  

Insurance companies have revamped their coverages and policies towards mental and nervous claims, including depression. Newer DI policies and almost all group STD/LTD policies now have clauses limiting such claims to 24 months of benefits. If you were filing a depression claim and had an older policy that did not include these limitations, insurance companies would sometimes try to  “buy back the policy” and get you to agree to a settlement to close your claim and cancel the policy.  This would allow the company to escape any future larger liabilities based on the generous policy language.  I would like to provide five tips that will help you avoid pitfalls and benefit denial in your depression insurance claim. Continue reading

Insurance Company Manipulation of Herniated and Degenerative Disc Claims

Many people have some form of degenerative back condition, ranging in severity.  Certain activities and professions can aggravate these symptoms into a condition that makes working almost impossible.  Several types of doctors, such as interventional cardiologists and radiologists, are susceptible to back injuries and herniated discs from wearing heavy lead aprons.  While there are several types of surgeries that may help relieve symptoms, including discectomies, insertion of rods and pins, and spinal fusions, these surgeries do not always work.  Before and even after such surgeries, patients can suffer from numbness, weakness, and loss of sensation in their extremities.  When the conditions become unbearable, many people decide to stop working and file for their disability insurance benefits.  However, getting your disability claim paid is not as simple and easy as it was promised.  Here are a few ways insurance companies defend against these claims to delay or not pay benefits. Continue reading

Disability Claims caused by Fibromyalgia: Specific details needed, and a lot of them!

One of the medically debilitating diseases that frustrates insureds the most is fibromyalgia.  Fibromyalgia is usually diagnosed as a syndrome of symptoms that insurance companies feels entitles them to deny claims outright or use heavy-handed investigative practices and techniques that delay or reduce benefits.  Insureds are also mislead by Internet articles and “experts” telling them inaccurate facts about fibromyalgia and disability insurance.

Fibromyalgia Tips

Insureds with fibro often don’t know what to say or how to address requests for information and inadvertently make statements that lead insurers to deny the claim based on stereotypes rather than approving the claim based on their actual restrictions and limitations.

Many times, an insured will go to their insurance agent, asking what they should say to claims examiners or what they have to provide to get their claim approved.  Agents:  Fibromyalgia is a very difficult disease to describe, diagnose, and prove.  Be sure your clients are well prepared, or they may blame you (along with the insurance company) if their claim is denied!

Here are some ways to be better prepared.  These types of statements, although accurate and a good faith attempt by insureds to describe their fibromyalgia symptoms, can be misconstrued by claims examiner or field representatives.

I have good days and bad days

Using the good day/bad day model is a commonly used description of how fibro affects people.  Insureds should NOT use this phrase because it suggests that healthy (i.e., non-disabled) people never have bad days.  Of course – we all do!  So, saying you have good days and bad days is too ambiguous to be diagnosed as a symptom of a disease but rather just the ebb and flow of everyday life.  Claims examiners won’t view this comment as credible and can often use that ambiguity as a lack of evidence and a reason to deny benefits.  Never use ambiguous, overly broad phrases.  Always be very specific with what you can and cannot do.  Take the time to be very specific and detailed about how you feel before, during and after performing (or attempting to perform) activities.

It hurts all over.

Often, it can feel like fibromyalgia is causing pain all throughout your body, but one of the most prevalent symptoms of fibromyalgia are the 18 specific pressure points at which pain occurs when touched with pressure.  Saying that it hurts all over can actually convince your insurer that you do not have fibromyalgia at all!  Be prepared to list your specific pressure points that hurt when asked by the claims examiner.

I sleep all the time, or I’m in bed all the time.

Insureds often do not realize that the statements made to the claims examiner are taken literally.  Statements that over-generalize such as these can lead to surveillance.  When the insurance company catches you not in bed or not asleep, they can use it as a reason to delay or deny your claim.  Fibromyalgia as well as some of its treatments often cause fatigue.  But your claim will be much stronger if you clearly point out what is causing your fatigue, then describe in detail how that fatigue specifically impacts your life.  Examples are a start, but take the time to be as complete as possible.  Showing that you are following your doctor’s orders can also help get your benefits paid on a timely basis.

I have brain fog or fibro fog.

Brain fog is a term used all over the Internet, and even by many medical professionals, to describe the haziness and loss of short-term memory that occurs in a number of diseases.  When dealing with claims examiners, take the time and effort to describe all of the actual symptoms and avoid generalizing them into one term.  Explaining details, such as forgetting important things and having trouble finding words, is a far more beneficial approach.

I’m taking herbs and treating with alternative medicine.

Alternative medicines are becoming more popular in the conventional medical world.  Disability insurance companies will expect you to use more conventional treatments for fibromyalgia, such as anti-depressants, if prescribed by your doctor.  Using herbs and alternative medicines in addition to conventional treatments is acceptable, but using them alone may be misconstrued as a lack of regular care and treatment.  That’s one of the phrases used to deny claims.  Have an open and on-going dialogue with your doctor as well as your entire care team so that you get the treatments that help you – and satisfy the requirements of your disability claim.

Staying away from overly broad statements and generalizations like these will help raise fewer red flags in your claim file and give claims examiners less reason to begin invasive techniques to delay or deny your claim, like surveillance, IME’s, and field representative interviews.

Remember:  When talking to a claims examiner, the best thing to do is be very specific and calm.  If you need to, take a break.  Take all the time you need – there is no hurry.  If your condition causes any level of confusion, try to communicate with claims examiners in writing.  Never generalize your statements.  Always realize claims examiners are working for the insurance company, no matter how friendly they may come across.

For more information on how to handle your insurance company or for specific advice on your claim, please visit our website or call us toll-free at 855.828.4100.