We often have clients come to our firm not with specific questions but wondering about their insurance company and worried about having their disability claim denied. There is no simple answer to this issue. Every case is unique, and the best strategies are different depending on the circumstances. However, in order to better help insureds understand the claims process, we’ve put together a list of the most common mistakes made by insureds everyday.
- Filing an Incomplete Job Description
The job description is possibly the most crucial piece of evidence when filing a disability claim. It tells the insurance company the exact tasks your occupation entails and sets the stage to prove how your disability effects these responsibilities – the basis for many claim approvals or denials. Many insureds list their job title (like physician or VP-marketing) or just make a basic list of their general duties and responsibilities (like treat patients, organize meetings, complete paperwork and reports) when they could and should be detailing the many specific duties to provide the basis to show the impact of their restrictions and limitations. For example, if you have a herniated disc, your insurance company may assert that you can still “organize meetings.” Make sure the insurance company has proof of and understands the extent of your job duties. Include the details of what “organize meetings” actually entailed in your job, for example that that you had to travel by air and car all over the country to attend meetings, requiring hours of travel and much walking and carrying oversized materials. Your claim becomes much stronger with a more complete and accurate picture of your occupation, including those duties you are unable to perform due to your restrictions and limitations.
- Exaggerating or Understating the Condition and Symptoms
Many insureds think they should overstate their conditions when explaining their symptoms and issues to the insurance company. This can lead to the skepticism of a claims examiner being increased to a more cynical level. Using the same herniated disc example, if you report that you cannot get out of bed for days at a time and cannot walk outside without assistance, you are establishing a relatively extreme impairment level. When the insurance company hires a private investigator to perform surveillance who records you simply taking out the trash or going to the grocery, you have just given the insurance company a basis to deny your claim.
Understating your condition can also result in a denial but for the opposite reason. There is no reason to be stoic about your disabling conditions or your restrictions and limitations and make yourself sound healthier than you actually are! It is not a time to be polite by not going into detail about the extent of your symptoms and restrictions or limitations. The insurance company will base their decision on your self-limited statements. It’s important to be honest and complete when asked to describe your symptoms, your restrictions and limitations, and your daily activities.
- Filing Incomplete or Unspecific Medical Records
Many doctors are unaware of the significance or too busy to sit down and thoroughly fill out the claim forms required by the insurance company. This is not to say they don’t care, but they are often overwhelmed by demands from insurance companies – their own as well as yours. Doctors can also be even more unclear than their patients when it comes to the important symptoms and material and substantial duties of their patient’s occupation the insurance company is looking for on the physician statements. It’s a good idea to take the time with your physicians to discuss your symptoms and how they relate to your occupation in the context of your disability claim. It may be beneficial to hire an expert to help walk you through your symptoms to clearly prove your disability claim to the insurance company.
Accepting a Mental and Nervous Determination Instead of a Physical Disability
Most newer disability policies have a 12 or 24 month cap on benefits from mental and nervous conditions. Insurance companies are looking to reclassify claims because of this limitation. By reclassifying claims that may have started out a physical disability to a mental and nervous disability claim the insurance companies are able to reduce their liability. This issue relates to the last point: your doctor must be very specific in describing your symptoms and functional capacity. Many people try and work with chronic pain from a back problems, but this pain may become unbearable and cause them to become depressed. If an insured files a disability claim in this scenario, the claim should be pursued for the back problems and chronic pain condition, which may not have a benefit limitation, in addition to the depression.
- Accepting a Residual Claim Instead of Total Disability
Most disability policies have clauses that differentiates between total and residual disability. Without going into too much detail in this overview, a disability claim is usually considered a total disability if the insured is unable to perform material and substantial duties. The claim is considered a residual (or partial) disability if the insured is able to perform some of their material and substantial duties. Insurance companies like to look past the required duties and jump to the income of the insured in order to back into a residual claim, when the job duties almost always guide this decision. No matter your current income level, if you cannot perform the material and substantial job duties, you are considered to be totally disabled in most policies.
- Not Realizing the Effects of Social Media
This topic was discussed in greater detail last week, but it has become such an important factor in claim investigations that it is worth repeating. Many people like to portray a “second” life on social media networks with their friends. These sites are the only places many disabled insureds can feel normal and like a regular part of society. However, insurance companies may not look at it this way. If you are active in groups or forums that support activities that your restrictions and limitations indicate that you can’t do, the insurance company may try and use this against your claim. It’s important to remember that everything about you on the Internet can be found by insurance company investigators, and it’s next to impossible to completely remove something once it’s out on the Web.
- Not Properly Considering ERISA Regulations
Most group disability policies as well as some individual policies are subject to ERISA. ERISA was originally intended to protect employees, but many of its rules and regulations end up causing more harm than help for insureds who have to go through the disability claim process. ERISA has strict deadlines, information requirements, and file restrictions that can severely impact the rights and abilities of insureds after certain points in their claims. It is important to discuss these rules with an expert, such as a disability claim advocate or an experienced attorney, to make sure that all of the necessary information and documents are included in the claim file before it’s too late. I go into more details on ERISA guidelines here.
- Waiting Too Long to Seek a Diagnosis and File a Claim
Successful people are rightfully proud of their career achievements and enjoy what they do for a living, so it makes sense that they wouldn’t want to stop working. In the long run, this decision can end up hurting a disability claim. Many policies require an insured to be under the regular care of a physician and have reduced or stopped working to qualify as the date of disability, not necessarily when the insured began to suffer from his or her restrictions and limitations. If you have been reducing your job responsibilities prior to filing a claim, your material and substantial duties at the time of disability may have been simplified and reduced, making your disability claim that much more difficult to prove. Likewise, if you’ve become disabled and don’t file your claim, there may be restrictions and deadlines that hurt your claim. It is important to seek medical care as soon as you’re suffering work restrictions and limitations and to prudently decide when and how to file your disability claim.
- Trusting the Insurance Company to Be Fair and Do The Right Thing
Insurance companies will tout how quick and easy their claims process is when you are purchasing a policy from them or even when you request claim forms. But this process becomes anything but quick and easy as the claim process unfolds. Under the guise of trying to prevent fraud and maintain “integrity,” insurance companies teach their claims examiners to behave like your friend and convince you that they are on your side, when these statements are carefully scripted to gain your trust and make you slip up into saying something they can use against you and your disability claim. Claims examiners and their managers earn bonuses based on achieving certain claim ratios, so it is misleading to say they aren’t biased when their compensation depends on how many claims are paid or denied. It’s important to have an expert help you with your claim, someone you know is on your side and help you every step along the claim review process.
These tips scratch the surface of the mistakes that insurance companies will try to capitalize on in order to delay or deny your disability claim. It’s always important to get expert help when filing a disability claim, especially when you consider how much money is at stake over the lifetime of a policy.
If you have seen any of these scenarios happen to a friend or loved one or have had the unfortunate experience of falling into one of these traps yourself, we are here to help! Call us at 855.828.4100 or visit our website for more disability claim help. If you have any more suggestions for this list or would like to tell your story, please comment below!