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If you have had your claim denied, or if your claim was granted and then later terminated, you may be eligible for substantial additional benefits.
What is It?
Disability insurance is insurance that will insure you from physical injury preventing you from working. There are two important components to this type of insurance. First, is the type of injury which they are insuring. Secondly, is the employability of the injury. Let’s discuss each.
These policies generally insure a person from either accidental injury or injury due to a sickness. So generally any type of physical injury is covered as long as it was not the result of your personally hurting yourself.
The next important component is how this injury affects your ability to work. Most policies insure a person from injury or sickness for the first 12 or 24 months if the injury or sickness keeps them from doing their own job. So if you are a brick layer and hurt your back, you can’t do your job, so the insurance company will have to pay you your monthly benefit for the maximum benefit period – 12 to 24 months while you cannot work.
After this 12 or 24 months of not being able to do your job, most policies then state that after this period you must be disabled from doing ANY job. So if you can’t do your own job, then you get benefits for 12 to 24 months. When that time runs, you have to prove that your injury keeps you from doing any job. This is called the “any occupation” clause.
Disability insurance can be a very good thing to have. Although, you have to understand if your policy has an “any occupation” clause, this seriously limits your benefits and makes your burden of proof in trying to get the benefits much harder. One important point worth mentioning is that if you are injured in a work related accident most disability policies will not cover you. So if you have a work related injury that is preventing you from doing your job, then you must file this under your employer’s workers compensation policy. Your disability policy will most likely not cover this event.
Where to Look?
If you purchased this policy on your own and can’t find it contact your agent or the insurance company. By law, if you request your policy, they must give you another copy. If you got this insurance through your employer and can’t find your policy, then ask management to give you a copy. Again, by law they have to provide you with a copy. If your employer supplied your disability policy then the law requires that your employer help you get the benefits offered. Another important point is that many disability policies have serious limitations on conditions that are considered forms of mental illness. Often these are depression and general psychological problems. Read and be aware of all these limitations before you make your claim.
What do I do if I have a claim?
First, your claim must be the type of claim covered. You must read your disability coverage language very carefully. Many policies define what will be a disabling injury or sickness under the policy. Once you fully understand what coverage your policy provides, you are then ready to make your claim. Remember, if you make a claim and have not read your policy, you will probably do or say something that will hurt your claim.
Make sure that you have the type of disabling injury or sickness that you are required to have under your policy terms. Your policy will tell you the conditions not covered. Next, you will have to make a formal claim. Many companies require you to use special forms to make a claim. Call the claims number provided in your policy documents and ask that they send you any of the forms required. Once you receive these forms, take great care in completing them. Many times the insurance company will use these forms against you. Make sure you tell the truth. Also make sure your disability is what is covered in light of what the insurance company defines as a disabling injury or sickness. Make sure you use the correct forms and that you complete them, providing accurate information. Also, note that many companies require that these forms be submitted within a certain time frame. Look for these deadlines and do not let them expire. (Snooze you lose). Another thing you should do during the claims process is keep a journal. If you don’t write everything down you will never remember. This process will drag on for months, if not years. Do you think you will remember? You won’t! Write it down. Write down every rude comment made. Write down every time you call and leave a message for someone to call you back. This journal will be your best friend if you have to sue them, which you probably will.
All disability insurers will require that you get your doctor to complete forms answering questions about your conditions and your ability to do your job and others. This is very important to discuss with your doctor. You must make him understand that you apologize for any inconvenience but that without his help you and your family will not receive these much needed benefits. Be nice and appreciative – this will go a long way. These forms must be completed and the insurance company will ask for them on more than one occasion.
The insurance company will request, receive and review all of your medical records. It is vitally important that you are honest with all of your medical providers and that you do not exaggerate your medical condition. The insurance company will read what you tell your doctors and they will then hire private investigators to watch you to make sure you are telling the truth. Be honest – it will always help your case. You are filing the disability claim – the insurance company is entitled to all of your medical records. If you intentionally leave a doctor out, they will deny your claim.
One of the most important things you can do to help your claim is build good relationships with all of your medical providers. If the doctor likes you, he will want to help you. If you are ugly to him, he will be ugly to you. When the company asks your doctor if you can work you want him to say no. You want him to support your claim so support everything he is doing to make you better. This will go a long way.
Next, many times the insurance company will ask you to provide a recorded statement. This is designed to get you to tell them the facts and to also get you to say something that will benefit the insurance company in denying your claim. Insurance companies will often use this recorded statement to later say you have no coverage or your claim is worth less money than it is. Be very careful with this statement. First, we recommend that you speak with an insurance lawyer before you give such a statement. If you choose to go on your own, then be careful. Be truthful and do not exaggerate or guess about anything. Above all, read and understand your policy before you open your mouth.
Keep a diary. This process may go on for months, even years. You will never remember what they say or how they treated you. Every time you call and leave a message, write it down. Every time you get a new adjuster, write it down. Every time they are rude write it down. This diary will be of great help if you have to sue them.
Do as much investigating as you can. Your policy states that you will receive money if you are disabled. It is not the insurance company’s responsibility to prove you can’t work. It is your responsibility. Be smart. Think about what will help you prove this, and do it. With the insurance companies, you can’t have too much evidence.
If you are thinking, I don’t have time for this nonsense, then think of it this way: If your coverage is $5,000 a month, would you spend one afternoon of your week to earn $5,000? Remember, this is your money at stake and they will do whatever they can to keep from paying you what is rightfully yours. Do your homework. Get out there and prove that you are disabled.
If you are sick or hurt get the medical treatment you need. Not only is this the thing to do for your own health, but it is very important that your sickness or injury is documented by a healthcare professional. If you say it hurts or I’m sick, that’s one thing, but if a doctor says it hurts or you are sick, that’s another story. Get medical help and attend all of your medical appointments on time. Remember, what you say to your healthcare providers is being written down. Only tell them the truth and do not exaggerate. The insurance company will get all of your medical records. They will read them and if you are exaggerating or telling stories they will use this to help deny your claim. Be honest, it will help later.
What to do if my claim is denied
First, you must understand that because you or your employer purchased this insurance, the insurance company owes you a special duty of care. This simply means that they must adequately investigate your claim in a timely manner. They must also look over all of the facts discovered and logically evaluate these facts, giving you the benefit of any doubt. Many times, insurers will deny a claim because they say they don’t have enough information. If your insurer is saying this, make sure that you provide to them all that they need to make a fair decision.
It is very important for you to make sure your insurance company documents the exact reason why your claim is being denied. If your insurance company has told you that it is denying your claim without specific reasons, you should demand that they forward to you in a letter the exact reasons why your claim is being denied. Once you look over their stated reason, you should attempt to address it with them if possible. An example of this would be if they deny your claim based upon the absence of certain materials such as medical records. Get all of the medical records they say they need as soon as possible.
After the denial, it is very important for you to determine how much time you have to respond. Some companies provide appeals processes for denied claims. You must read over the denial material sent to you or even ask your adjuster if there is an appeal process. If there is such a process, you must decide if you want to appeal or move forward with a civil lawsuit. Some federal and state laws require that you go through the appeals process before starting a civil lawsuit. Also, each state provides a certain period of time in which you must act before your time runs out to bring a lawsuit. Once you have your claim denial, it is important for you to get a lawyer to help you, who is familiar with the insurance laws in your state. It is very important not to let your time run out. After it runs, you will not be able to bring any lawsuit against the insurance company.
Again, you should speak to an insurance lawyer as soon as possible to protect all of your rights. Remember, every penny they don’t pay you is a penny they put in their own pocket. The insurance company is not your friend, so don’t expect them to pay if you don’t do your homework.
Here’s a list of disability insurers:
U.N.U.M.
Aetna;
AIG;
Assurant;
Assurant;
CIGNA;
CNA;
Guardian;
Jefferson Pilot;
The Hartford;
Mass Mutual;
MetLife;
Mutual of Omaha;
New York Life;
Reliance Standard Life;
Principal;
Standard Insurance; and
Union Central