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.
Using a watered-down version of the occupation
Back problems often result from degenerative conditions that many professionals will try and work through. As the pain gets worse, people may try to continue working by refocusing their job responsibilities, trying to trade more physically demanding duties for different aspects of their job until they cannot stand to work any longer. When the disability claim is filed, the insurance company looks at the occupational duties and responsibilities being performed as of the date of disability. Many insureds equate this date with when they finally stopped working rather than when they became disabled, which may be a much earlier date. Also, some insurance companies will not allow a date of disability until a doctor has deemed an individual unable to work. When the insurance company evaluates the occupation, the change in job duties and responsibilities caused by the disability are ignored, and claims are denied on the basis that the insured is able to perform the watered down occupation.
To avoid this, determine and insist on an accurate date of disability and be under a doctor’s care as soon as you are no longer able to work as much or as well as you used to. Although many people have worked hard to get where they are and do not want to stop working, caution and preparation are needed to ensure that you are able to obtain your rightful disability benefits.
Enforcing stringent care & treatment requirements
Many people prefer to avoid surgery or other invasive procedures when dealing with an injury or condition that is not life threatening. Insurance companies capitalize on this fear and trepidation and turn it into a reason to deny your claim. When an insured can’t work and chooses to pursue more conservative treatments rather than more risky procedures, the insurance companies may believe that the insured is choosing to not work, which can be developed to deny the disability claim and not pay benefits. Avoid this pitfall by understanding, discussing, and documenting any recommended courses of treatment with your doctor, whether the approaches are conservative or involve surgery.
The “Good Day – Bad Day” Argument
As many with chronic back problems know, there are good days and bad days. Insurance companies like to use surveillance to follow insureds and investigate the insured’s activities. Once surveillance is obtained, they will cherry-pick through the data and potentially misconstrue the abilities of the insured. For example, if a private investigator sees an insured out grocery shopping or driving to the office, the insurance company will often stop paying disability benefits. Even if someone happens to feel good for one day or does something that will cause pain later, be aware of what’s reported on the monthly claim form. Be aware of your surroundings and anyone suspicious or just seeming to be there. Also, be very careful and thorough in describing what you can and cannot do on the claim forms and detail any activities that caused pain.
Changing the disability from total to residual
This is a two-fold strategy that can help the insurance company and hurt the insured. Many disability policies provide total disability benefits only. Claims are not paid unless the insured is deemed totally disabled, which is often hard to prove and often leads to the denial of the claim due to only being partially disabled. For policies that have total and residual coverage, the issue can be much more subtle. Insureds trying to claim residual disability benefits are required to provide large amounts of paperwork every month, and the insurance company can delay or deny the claim if instructions are not followed and documents sent. Also, insureds are not guaranteed any certain amount of benefits each month, causing more stress and anxiety. The insurance companies may even try to capitalize on that stress and anxiety by offering to settle residual claims for much less than they’ve already reserved, pennies on the dollar.
There are also business reasons to define claims as residual rather than total. When an individual is collecting total disability benefits, the total amount is set up as a reserve and recorded as an expense. On a residual claim, only a portion of the total amount is reserved, based on the assumption that the entire claim will probably not be paid every month. Reclassifying claims from total to residual allows an insurance company to reduce reserves and the accompanying expenses, which lowers the loss ratio, increases income, and achieves management performance goals.
These four points just scratch the surface of the tactics and approaches that disability insurance companies will try and use to protect their bottom line and deny legitimate claims. Each one of these could have an entire book devoted to them to relate all of the horror stories and experiences that we have heard from our clients and others in the industry. If any of these tactics sound familiar to you or you would like more information on navigating the rough waters of the disability insurance world, please contact our offices at (855) 828-4100 or fill out a contact form at our website, Royal Claims Advocates.