3 Major Questions of a Total and Permanent Disability Claim

While most sufferers of chronic back pain are able to recover and return to work in varying capacities, there are many people who experience such severe and debilitating pain that they will never be able to hold a normal job again. Claimants who suffer from such severe conditions are initially approved for their disability benefits, but this may be just the beginning of a long and winding road for claim investigations that can be opened and reopened for years on end. Insurance companies won’t acknowledge what total and permanent represents and require regular and appropriate care for the conditions causing the pain throughout the duration of the claim and can also require other documents ranging from tax returns to activity logs. Insurance companies can also reopen investigations at any time and restart the review process all over again. If you have been approved for benefits and don’t expect to return to work anytime soon, there are several issues you should consider to help reduce the stress going forward in the claims process.

Three of the most common issues we hear about from claimants in this situation are surveillance, settlements, and what the insurance company considers to be appropriate care for the condition. I will touch on each of these topics as well as a few other key issues prevalent in these types of claims.

private investigatorSurveillance is the most common issue many of our clients worry about. Constantly having to worry about a stranger watching and recording your every move is a scary thought for anyone who cares about privacy, and it’s a very real concern for many people on disability claims.  If your medical condition is so severe that you’re suffering from totally disabling back pain, your chances of facing surveillance of your activities that impeaches your claim are relatively low. However, there are two periods during long term claims when a claimant should be aware that surveillance is more common.  

  1. During a transition to a new claims examiner. Often, claim examiners are assigned to review all of the “old claims” to see if there are any claims they can stop. If you’re one of the unlucky ones, be prepared for a whole new investigation into your file, including both Internet searches and surveillance.  
  2. At the request of the reinsurance company. Insurance companies often have insurance themselves for their claims. This type of insurance is called reinsurance. If your claim falls under one of their reinsurance treaties, the claim department may be ordered by the reinsurance claim examiners to do continuing reviews and investigation of your claim if the reinsurance company thinks the claim may be able to be terminated.  

If your claim has fallen into one of these categories, the first red flag you will see is often a form sent to you asking you to describe your daily activities in detail from the time you wake up until you go to bed. Fill out this form carefully, completely, and accurately. Too often, claimants think they have to paint a certain picture for the claims examiner and exaggerate their conditions.  Make sure your statements are consistent with what you’ve reported to your doctors and what you’ve previously reported on the claim forms. If you overstate your limitations or understate your activities, these may used against you if surveillance shows that your claims are false and misleading. There are other issues that claimants who are permanently disabled may need to know, and we’ve written a previous article about surveillance and how to effectively deal with investigators.   

Many claimants are also curious about the possibility of receiving a settlement if their physician has declared them to be permanently and totally disabled and the insurance company is paying their claim. While this may seem like a good idea in theory, settlements are rarely beneficial to the claimant. Insurance companies offer settlement only to reduce the liability they already have on their books for a particular claim. In order to do this, the value of a settlement is far less than the present value of the lump sum of all the disability benefit payments the claimant would expect to receive over the course of the benefit period. This article sheds some light on the way settlements are handled and how the insurance companies come up with amounts to offer to settle a claim. Unless you’re in desperate need of the lump sum amount, it’s far more financially  responsible to continue to receive monthly payments over the course of the benefit period.  

diagnosisThe other major issue our clients commonly run into during extended disability claims is the requirement to receive appropriate care (by the insurance company’s definition) during the entire course of the benefit period. While traditional therapies and doctor’s appointments may not be working for some medical conditions, this doesn’t mean that claimants  can just stop obtaining them. Insurance companies have definitions and requirements in their policies of what’s consider appropriate care, and claims examiners can (and do) stop paying benefits if you aren’t receiving their definition of care. (A full explanation of this issue can be found in this article.)

Even if your treatments aren’t improving your medical conditions or reducing your pain, you must discuss the requirements of your disability benefits with your doctors. It may be a matter of continuing to schedule appointments and receiving treatments as long as they don’t cause any more harm or discomfort. You may seek out additional alternative or non-traditional therapies, but they cannot replace generally accepted, standard treatment protocols. In addition, you may be required to continue to see your doctor – even if your doctors say it’s unnecessary. For many permanent back pain conditions, there may come a time when doctors can do little more, making it medically unnecessary to continue to see the patient. Even though this may be true, the insurance company can demand that these appointments continue on throughout the benefit period. Claims examiners may even require monthly claim forms be filled out by your physician reaffirming your condition and disability.  Hint: The administrative burden of reporting the same conditions time after time after time can be eased by a good copy machine! 

Being permanently disabled is incredibly difficult and is only made more problematic by seemingly arbitrary requirements of the disability insurance company. Throughout a disability claim, having to worry about issues that are created by continuing  investigations serves little other purpose that inhibiting any sort of recovery or semblance of normalcy you’re trying to gain. To reduce the stress on your life, the best option is to prepare for their questions and investigations in advance and have an understanding of why they’re doing what they do. If you’re prepared and keep working to be completely clear with your medical conditions, restrictions and limitations, and information for your disability claim, you will be much more likely to receive the disability benefits you deserve.  

If you have any more questions about your chronic back pain disability claim, or any other type of long-term disability claim, please don’t hesitate to call our offices toll-free at (855) 828-4100 or visit our website to fill out a free consultation.

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