I deal with insurance companies
every day. Why should this case be any more complicated?
What can I do to maximize my chances
of success in filing a claim?
What kind of doctor should I see?
Which policy clauses are most likely
to be used as grounds for denying a claim or reducing
benefits?
How can I find out more?
I deal with insurance companies every day. Why should this
case be any more complicated?
For various reasons, in recent years the disability insurance industry has
become very aggressive about denying and terminating
claims and minimizing payouts. Insurance companies
literally have forensically trained teams of experts
reviewing every document in search of ways to
defeat the claim. They can be calculating and
systematic, especially in handling high-value
claims like yours.
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What can I do to maximize my chances of success in filing
a claim?
One basic precaution is to choose a doctor who will give your claim maximum credibility, specifically one who is well-credentialed, forensically trained, and specializes in your exact disabling condition. When you see the doctor, be sure to carefully explain your professional and occupational responsibilities and duties, especially as they may be affected by your disabling condition. For instance, if your job entails long hours of cognitive functioning at an executive level, or if your job requires physical skills or demands, make sure your doctor is aware so he or she can make a full and accurate assessment of your ability to work.
Other key crucial steps include: understanding your own contractual obligations under your policy and identifying issues that might create problems for or defeat your claim- likely candidates include the incontestability clause, pre-existing condition clauses, and the nature and extent of the disabling condition. It is also essential for your doctors to learn the responsibilities of your "own occupation" and then to clearly establish any and all restrictions and limitations you face as a result of your condition. Back to top
What kind of doctor should I see?
The medical assessments that accompany your disability insurance claim have the best chance of success if they come from a doctor who specializes in your disabling condition. Look for a treating doctor who is well credentialed, forensically trained, has experience with insurance claims, and is willing to go to the trouble of providing your disability insurance company with the completed relevant paperwork. You should also be careful to explain to the doctor exactly what it is that you do in your work and how it might be affected by your disability. If you need to multitask, function at an executive level, and/or perform physical skills or demands, your doctor should know about it. Back to top
Which policy clauses are most likely to be used as grounds
for denying a claim or reducing benefits?
One common reason claims are denied is because of the "incontestability clause," which allows insurers to contest policies that have been held for less than two years. (Sometimes the carrier may have the right to contest the policy or claim even after the two years have passed. This depends on the specific language used in the clause, and the facts of each claim.) Another common cause for denial, especially in cases of addiction and mental health claims, is a determination that the disability was a pre-existing or non-disclosed condition. A third common reason arises in "own occupation" policies—if the insurer determines you are still capable of performing your material and substantial duties of your own occupation, it might refuse your claim, or take the position that you are residually disabled, instead of totally disabled, thereby reducing the monetary benefits to which you will be entitled, and even possibly the duration of the claim. "Own occupation" is often broadly interpreted so that companies can claim, for instance, that a surgeon is not totally disabled—even if a disabling condition prevents performing surgery. "Elimination periods" are sometimes used to give the insurance company a way to defeat or reduce duration of claims. In many other cases, especially addiction disabilities, insurance companies argue that a professional has the ability to work "but for fear of the risk of relapse" and they are therefore not disabled. Courts have upheld that in such cases benefits can be terminated. Back to top
How can I find out more?
There have been a multitude of changes in this area in recent years, and it is more important than ever to educate yourself about your disability policy and the issue you may face when considering filing a disability claim. Hopefully you will never need to use it, but if you do, you may have much to learn and consider. There are also a multitude of claim—likely which medical professionals you choose to treat your disabling condition to what is stated on the claim documents and records you submit to the disability insurance company can affect the outcome of your claim. These matters are discussed in more detail in the following articles: Back to top
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