Presenting a claim under a disability insurance policy is sometimes difficult and frustrating. You are likely at a disadvantage when dealing with your insurance company under normal circumstances. Insurance companies are in the business of dealing with insurance claims. They have usually established policies and procedures for dealing with almost every conceivable situation.
On the other hand, it is unlikely that you have ever presented an insurance claim, let alone one arising from a disability. Because of your disability, you are potentially at a greater disadvantage when dealing with your insurance company. Whether your disability is solely physical or psychological, or a combination of both, it is important to carefully present your claim for benefits. Insurance companies are for-profit entities. They have a direct economic motive to deny insurance claims if at all possible. Unlike in your dealings with other businesses, don’t assume that the company will the follow rule that the “customer is always right.”
Sometimes, insurance companies have an established practice of automatically denying most claims. Unfortunately, many insureds, not knowing better, simply drop their claim. Don’t give up. Make sure that you pursue all available alternatives to get your insurer to accept your claim. There are some key points to properly (and successfully) presenting your claim and to avoid mistakes in the presentation of your claim that could come back to haunt you should a dispute arise concerning your claim. Each claim is different. Some or none of this information may apply to your claim.
It is crucial that you obtain appropriate legal advice in your jurisdiction. It is impossible to provide comprehensive information applicable in all jurisdictions in the context of just one article. Following are some tips that apply to the presentation of most disability (and many other) insurance claims.
Know your rights and duties: An insurance policy is a contract. Like any other contract, your rights and duties are largely set forth in detail in the policy. If you don’t already have a copy of your policy and all associated documents (e.g. application, pre-policy correspondence, brochures), get them before you present your claim. Some insurance companies attempt to, in essence, change the terms of the policy by requiring insureds to provide much more information and to satisfy much more strict standards for benefits than as agreed in the policy of insurance. The easiest way to know whether your insurance company is attempting to take advantage of you is for you to read the policy and understand your rights and duties. For example, most policies specifically identify the steps that you must take in order to properly present your claim. Although you generally should be able to rely upon your company to provide the necessary forms and to guide you through the process, you should not blindly depend upon it doing so. There is simply too much at stake for you not to protect yourself by knowing your rights and duties. Courts generally assume that you know the terms of your policy.
Get appropriate medical advice: Because disability is necessarily a medical determination, most disability insurance policies require that you are being treated by a doctor. The policy will generally require that your doctor complete a form and provide information to your insurance company regarding your medical condition. A good doctor is the best way for you to not only get well, but also to provide accurate, detailed and timely information to your insurance company in connection with your claim. The processing of many claims is delayed because the insurance company simply does not have sufficient medical information upon which to conclude that insureds are disabled. Make sure that your doctor will cooperate with you in presenting your claim and in providing supplemental information during the life of your claim.
Cooperate: Most insurance policies expressly provide, and the law almost always implies, that the insured has a duty to cooperate with the company in connection with a claim. Generally, this means that you must provide timely and honest information in response to your insurer’s requests. Some policies require that you submit to independent medical examinations and take other action to cooperate, upon the request of the company. The extent of the necessary cooperation will depend upon your particular circumstances. If the information or action requested by the company is at least reasonably and rationally related to a determination of whether you are entitled to receive benefits and, if so, the amount of benefits, it is important that you comply with the request. Your failure to cooperate, if it precludes the company from making an informed decision concerning your claim, may result in a forfeiture of benefits. Of course, the company must also act timely and cannot take advantage of your duty to cooperate by requiring information beyond that required by the policy or beyond what is reasonably necessary to make an informed decision concerning benefits.
Don’t tolerate delay: It is almost universal law that insurance companies must act promptly in their investigation and determination of insurance claims. The company should always “keep the ball moving” by promptly requesting and obtaining necessary information. Once it has necessary information, it must promptly make a decision concerning benefits. You should not tolerate delays in the process. Continuously follow up with the company (preferably in writing).
Do it in writing: Document, document, document! This is perhaps one of the most important points. All too many times, if coverage is denied or a dispute arises, it turns into a “he said-she said” argument. The best way to avoid such a situation is to communicate in writing. Because insurers are big businesses, they usually have procedures for the documentation of everything that happens, from their perspective, on a claim. You should treat your claim like big business too. Make your communications in writing so that you have a clear record of the information that provide to and requested from the insurance company. Remember that anything that you write could become a 10-foot by 10-foot exhibit in front of a jury deciding your case, if a dispute should somehow arise concerning your claim. Do not write or say anything that you would not be 100% comfortable with a jury seeing or hearing. You have the right to request that the insurance company also communicate in writing. If you receive phone calls from the company, simply ask that the representative send you a letter confirming the information provided or the request being made.
Pay attention to the details: “The devil is in the details.” In all of your dealings with your insurance company, it is crucial that you pay attention to the big and little details of all aspects of your claim. Don’t simply “shoot from the hip” or provide what you believe to be the key points. Make sure you are complete, detailed and honest. If you gloss over information or skip items when providing information to your company, you may later be precluded from adding to or changing the information. At a minimum, such mistakes will surely make you look bad, even if the omission is unintentional, especially if a dispute should arise concerning your claim.
Get appropriate legal advice: As with all insurance claims, each disability insurance claim is different. Different rules and laws apply in each state. Each insurance policy is different. It is, therefore, crucial that you obtain appropriate legal advice to ensure that your rights are protected and that you comply with your obligations under your policy and the law.
Use your department of insurance: Many states have formed agencies for the purpose of, among other things, aiding consumers in insurance-related disputes. If you find yourself in a dispute with your insurance company, contact your local department of insurance. Depending upon your situation, the department may pursue recovery of benefits on your behalf. Most departments also maintain databases of claims against insurance companies. This is a great source of information. If you are involved in a dispute with your company, it is usually wise to see whether that company has had other similar claims made against it. The bottom line is that you should be careful in all of your dealings with insurance companies. Remember that this is the insurer’s business. They have been through thousands of claims and know what to expect and how to handle almost every conceivable situation. Because of the inherent uneven playing field, you need to thoroughly prepare and carefully protect yourself. Do not rely on just the information provided in this article. Disability benefits could become your sole source of income. The stakes are huge when dealing with a disability insurance claim. Get appropriate legal advice.
If you have questions about presenting a disability insurance claim, please don’t hesitate to contact us.