Working with disability insurance companies for years, the experts in our firm have seen many people and approaches come and go in the industry. Marketing philosophies clash with claim handling procedures, legal decisions change the language used in policies, insurance companies sell blocks of policies to other companies, management turnover lead to changes in how claims are handled, etc… To paraphrase a famous line – the more things change, the more they stay the same.
Unfortunately, many of these changes have negative consequences on the claims and lives of insureds. What may be perfectly acceptable in year two is no longer good enough in year three. Documentation that’s accepted by one claims examiner is disputed by another. In spite of this, the underlying fundamentals of disability claims remain the same: if you have the medical, occupational, and financial information to prove that you are disabled under the terms and conditions of the policy, you are entitled to benefits.
Obviously, most people are scared when they become disabled. Insurance companies tend to compound this emotion and add frustration and anger to the mix, doing too little to help their insureds when they’re the most vulnerable. So, some savvy attorneys and consultants try to capitalize on this powerful emotional brew by portraying themselves as uniquely fierce and able to fight and threaten insurance companies into backing off and paying claims. We’ve seen far too many claims mishandled by company examiners and/or poorly presented by advocates, and we’ve spent countless hours discussing how we would do things differently and better. Every firm is entitled to their own way of conducting their business, and today I’m going to go into our firm’s philosophy on how we handle disability claims and the adjudication process of our clients. We’d rather succeed quietly than fail loudly.
It’s the philosophy of our firm to succeed quietly rather than fail loudly. What does that mean?
When a claimant hires someone to help them with their disability claim, a common first step is for the advocate to swoop in, clamp down on communications with the insurance company, start barking out orders for the claimant and claimant’s medical providers, and make a show of telling the claims examiner that the rules have changed – the advocate is in charge now! The claimant feels better, like their advocate is taking control and handling the claim adjudication process.
Some claimants believe that they must hire an attorney to defend their interests in a disability claim. And sometimes litigation unfortunately can’t be avoided. The experts in our firm aren’t attorneys nor do we practice law or provide legal advice, but we have worked with many attorneys who have spent their careers researching how to defend (i.e., deny) disability claims. Insurance companies have floors of attorneys in their own offices and in syndicates of law firms located around the country, not to mention paralegals and legal assistants, who are specifically employed to handle claims, prepare and manage litigation (and sometimes more importantly, anticipated litigation), and deal with any compliance issues or complaints with state insurance commissions. They have well established standard operating procedures to handle claims from claimants who have “lawyered up.”
Insurance companies have enormous assets, entrenched trade and lobbying groups, and thousands of employees and even more outside consultants. They’ve been in business for decades. Really, it’s disingenuous to lead someone to believe that any advocate is going to be able to intimidate or push around an insurance company.
What happens when such heavy-handed tactics are engaged is that the rules for the claim do change – but not for the better. Claims examiners will simply refocus the insurance company’s approach to handling the claim. The claim is escalated or referred for “special handling” that almost never turns out well for the claimant. Such terms indicate that insurance companies are going to handle the claim in a more deliberate and cautious fashion. 
The claimant loses the benefit of the doubt. More resources are involved, dedicated to going through every aspect of the claim with a fine tooth comb – medical, occupational, legal, and financial. All correspondence is reviewed by legal professionals; previous statements are re-examined; field representatives are dispatched to interview the claimant and the advocate; the handling of the claim may be taken over by a member of the company’s Special Investigations Unit (SIU); medical records, treatments, and diagnoses are referred to in-house physicians; IME’s are scheduled; Internet and online database searches are performed by experienced investigators; tax returns and financial statements are analyzed by forensic accountants, etc… The high-skilled and trained professionals employed by insurance companies search for reasons to delay or deny disability claims, and they are exceedingly good at what they do. Even if a claim is paid in the short term, groundwork is being laid to terminate the claim in the future.
Based on our experiences, we believe that it’s more productive to help claimants while allowing them to be in control of the process. We work exclusively with our clients behind the scenes, making sure that all communications are understood and then handled in the best possible manner. Forms are accurately completed, adding details and information to clearly demonstrate that our clients are due their rightful disability benefits. In other words, we try to make the claim easy and obvious. The claims of our clients are almost always processed by claims examiners without any “special” handling. Avoiding any special handling or investigations reduces the time to have the claim approved by a claims examiner, ensuring benefits are paid as quickly and smoothly as possible.
Another tactic many advocates promote is to take an aggressive stance on limiting what “private” information, such as medical or financial records, are provided to the insurance company. This tactic is risky as it can slow down the claim approval process more than any other single decision. Many advocates believe that supporting information should be submitted just enough to support the precise issue behind the claimed restrictions and limitations, and only provide more information if required. Our firm takes a different perspective.
Based on our experiences, we understand that insurance companies have the resources to obtain the records they want, regardless of how much advocates may try to limit or control the information. We don’t think that information should be parsed and selectively provided or deleted to try to fit a certain scenario. It’s our philosophy to gather and provide all available medical records and demonstrate the requisite relationship between the medical condition(s) and the disability claim. When the claim is filed, we try to include every medical record from every source, even those that may not have directly contributed to the disability. This approach has several positive effects on the claim approval process. If all medical records have been provided to the insurance company, the excuse “they’ve requested and are waiting for records” is eliminated. Providing incomplete or limited records also allow claims examiners to start making assumptions and faulty conclusions. And, it’s never a good idea to let claims examiners obtain and review personal information and documents without any review or communication from the claimant. So, it’s our philosophy to provide all possible records at the beginning of the claim since the claims examiner will likely request them anyway. The information is presented in a manner that’s consistent with the disability claim and arranged to tell the story of the disability. Our clients get to provide the narrative of their disability, accelerate the flow of information, and reduce the approval time for their claims.
To illustrate our philo
sophy in action, here’s an example of how one of our clients benefited from our approach. Recently, a business executive retained our services to help in the transition of her disability benefits from short-term policy to long-term policy. She was suffering from a neurological disease and couldn’t perform the day-to-day activities of her occupation. She had talked to friends and even with other advocates who had given her some advice on how to handle her claim. So, she already had some history with her disability claim and the insurance company before we were engaged. After reviewing her claim along with her previous correspondence and dealings with the insurance company, we were able to anticipate some of the defenses the insurance company was developing to deny her claim. She was a little surprised as her benefits were still being paid, and she thought it was going pretty smooth.
Many claimants don’t realize that transitioning from short-term to long-term disability benefits often requires an entire new approval process with a new claims examiner. Most STD and LTD policies also have different clauses and definitions. Looking through our client’s medical records, we were able to see the specific information the insurance company could use to deny her claim and started to work with her and her medical providers to mitigate the manipulation of that information and re-frame her disability claim in a more accurate and complete manner.
Nine days later, she received a letter from her LTD claims examiner, raising concerns about several aspects of her claim and requesting additional (and different) authorization forms be completed and additional information be submitted. In order to respond to the claims examiner, we drafted a lengthy letter for our client that explained her disability in better detail. She discussed this with her spouse, and we revised the letter together. This back-and-forth process happened in real-time through our innovative client portal, a safe and secure way to instantly share information and documents between our firm and our clients. We also worked with her doctor to highlight certain test results and add a supporting narrative. After printing the letter and attaching the accompanying forms and medical records, our client faxed the package directly to the claims examiner. After completing this process, our client received a thank you letter from the claims examiner and electronic payment of her LTD benefits. Since then, our client has faced no more scrutiny other than having to complete the monthly claim forms and attending physician statements. Our client continues to receive her monthly benefits, and we continue to work with her to make sure her claim forms are complete and accurate.
Our firm is dedicated to providing the best possible solutions for our clients. Others (not all, but too many) involved in disability insurance claims take the approach that it’s necessary to be aggressive and combative with insurance company employees, perhaps due to a falling out with a former company or their own marketing agendas. We choose to focus exclusively on how best we can help our clients receive all of their disability benefits in a timely manner. Often, this means being professional with many insurance company employees whom other advocates would rather treat with contempt. The mission of our firm is not to make insurance companies lose but rather help our clients win. And in our experience, the most productive approach is to be discrete and effective, not create a spectacle. Theodore Roosevelt’s most memorable line sums up the sentiment of our firm: Speak softly and carry a big stick.
If you have any questions or would like to speak to one of our experts, please call our offices toll-free at (855) 828-4100 or visit our website for a free consultation.
Royal Claims Advocates 