Successfully Defending a Claim Against Denial

Today’s blog is my favorite type – a success story!  One of our clients has graciously allowed me to relate his story to our readers as an example of how having expert help and standing up for your rights can lead to a positive outcome in your disability claim.

Several months ago, our firm was contacted by a marketing executive who had a skiing accident in 2009.  Luckily he wasn’t injured other than a pretty bad concussion, a grade III.  He was suffering from the effects of his concussion, so his spouse contacted their agent who put her in touch with the claim department of their insurance company.  The executive applied for disability benefits and was approved for total disability benefits.  After two months of total disability, he decided to go back to work part-time and transitioned to residual disability benefits.  For the next two years, it seemed things were going smoothly, considering his condition, and he had no trouble with the disability claim process.  His neurologist continued to send in medical documentation every month, and the benefit checks kept coming in the mail.

After about two years of receiving residual disability benefits, he and his company mutually agreed that his work had become unsatisfactory.  Others in his department and the company were frequently having to cover for his memory lapses, and he was frequently taking leave to deal with the excruciating headaches he had been suffering since his accident.  Due to these complications, he and his physician agreed it would be beneficial to his treatment and well-being to change his claim back to total disability to try and fully recover from his accident.

At this point, the tenor of the claim adjudication process started to change.  While completing his claim forms to claim to be totally disabled, he listed the reasons for his inability to work as the inability to concentrate due to headaches and other symptoms of TBI, or Traumatic Brain Injury.  Unwittingly by the insured, he had just inadvertently opened an avenue that the insurance company was about to capitalize on to deny his disability benefits.

After receiving the new claim forms that reported the insured was no longer working, the claims examiner requested that the insured undergo an Independent Medical Examination, or IME, that the insurance company would schedule with a neurologist.  Having experienced no problems with the insurance company previously, the insured affably agreed and went to the appointment.  Shortly after he had his IME, he received a letter from the insurance company terminating his claim and denying him any future disability benefits.  The insurance company’s neurologist had come back with a report stating that the insured had no physical limitations due to TBI.  The insurance company also contended after the initial period of total disability, all subsequent benefits were the result of self-reported symptoms or mental and nervous conditions and were therefore subject to a 24-month limit on disability benefits based upon the policy language.  And since he had been receiving benefits for two years, no further benefits were owed, either total or residual, since 24 months of benefits had been paid.  It’s after receiving this letter that the insured contacted our firm and retained our services to understand and try to obtain his disability benefits.

Not just for this instance but really for any disability claim, it’s very important to always start from the very beginning and build a strong foundation for the claim.  This sounds simple and obvious – but far too often it’s overlooked or glossed over.  We talked about his actual occupational duties prior to the skiing accident that began his whole ordeal.  Reviewing his previous claim forms, our client had just written down his title of “brand manager” and described his job duties in less than 16 words.  As an executive in a large advertising agency, his job duties entailed far more than the overly simplistic description he provided for the insurance company.  By expanding and completing his job description, his occupational duties were more accurately described for the claims examiner as well as his neurologist, allowing them to better understand his occupation.

In addition, we worked with our client to improve his communication with his medical providers so that they better understood how to document our client’s diagnosis and symptoms.  Considering his more accurate and complete job description, his medical providers were also able to more clearly tie his restrictions and limitations to his inability to perform his occupation.  Based on this more robust information and documentation, the factors used in the IME report were reasonably able to be questioned and disputed.

As you may know from reading our blog, incomplete information or misstated symptoms on claim forms are some of the most commons reasons insurance companies are able to deny seemingly valid claims.  By educating our client and his physicians on the key words and concepts needed to substantiate the claimed disability, we were able to take away the ability of the insurance company to make assumptions or infer conclusions that were detrimental to our client’s disability claim.

At the end of this process, we helped compile a package of occupational and medical information to submit to the insurance company to appeal his claim termination and denial of benefits.  After reviewing the new and much more complete and accurate evidence, the claims department reversed their decision and retroactively reinstated our client’s total disability benefits.  Our client is now being paid the benefits he deserves every month while he focuses on his recovery, and the thorough evidence supporting his claim helps ensure his peace of mind.  The combination of clear and convincing medical documentation with a thorough and complete description of his occupation provided this insured with a rock solid basis for his claim that should withstand the on-going examination and investigation of the insurance company.

Looking back at this claim, clearly mistakes were made both by the insured as well as the claims examiner.  All claims don’t have to get to this point.  Hiring a disability claim consultant when you’ve become disabled and need to file for disability benefits allows experts like us to help your claim documentation from the beginning while keeping a focus on the big picture as well.  Removing these worries and stresses from your life allows you to focus on what really matters: getting healthy and returning to a life where you are not defined by your disability.  If you would like more specific information on your claim, please visit our website for a free consultation or call us toll-free at (855) 828-4100.

2 thoughts on “Successfully Defending a Claim Against Denial

  1. Pingback: 6 Potential Pitfalls of Your Chronic Back Pain Disability Claim | Royal Claims Advocates

  2. Pingback: 10 Ways to Protect Your Disability Claim in 2013 | Royal Claims Advocates

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