Disability Insurance Claims

Insurance companies will try to deny your claim in any way that they can. One of the most frustrating that we’ve dealt with is when insurers say that people aren’t eligible for disability benefits because they can still do things at home such as washing clothes, running the vacuum, and preparing food.

Basically, their argument is that the simple ability to take care of yourself proves that you can work and therefore means they don’t have to give you benefits. If your claim is denied for this reason, don’t give up so quickly. Whatever they may say in their documentation to you, housework doesn’t equate to the ability to perform a full-time job, and you need to fight back.

Last time, we talked about how just having long term disability insurance isn’t enough; your condition has to meet the requirements outlined in your specific policy. The provision we detailed in part one of this series is the definition of disability included in your paperwork. If you can’t meet your policy’s disability definition, you’re not going to qualify for benefits.

But that isn’t the only common provision out there, and today we’re going to delve into the elimination period, earnings caps, and other requirements.

If you have unexpectedly found yourself unable to work due to a disability, you’re probably wondering what rights you have to receive disability benefits and whether you’ll still have a job if you are able to continue working in the future. The short answer is that in certain workplaces, you will receive benefits and have limited protection under the Family Medical Leave Act. Let’s look at that answer in a little more detail.

What is the FMLA? The Family Medical Act was signed into law in 1993 and protects eligible employees who need to take an unpaid leave due to a family or medical emergency. The FMLA states that eligible employees can take up to 12 weeks of unpaid leave in the course of a year and, after they’ve used up their 12 weeks of leave, still return to the same or an equivalent job with their employer. During this time, the employee will continue to receive the same group health benefits that their employer would have offered them if they had been working during this time. Unfortunately, if the employee is absent for longer than 12 weeks, the employer can legally terminate them.

There’s absolutely nothing in your policy that gives your insurance company the right to hire a private investigator to watch you and record your daily activities, but that hasn’t stopped most of them from doing it more and more in recent years.

The idea is that by following beneficiaries around and watching them closely, they’ll catch people in the act of doing something they shouldn’t be able to do based on their condition and have a valid reason to deny your claim or stop payments.

Supposedly, it’s a way to cut down on fraud, but all too often it results in the insurance companies or the investigators they hire using shady practices to make it look like claimants are behaving badly when the truth is something completely different.

We’ve discussed IMEs here before and how insurance companies use them to deny claims and stop paying benefits for longer term problems, both for people under individual and ERISA-governed policies. Below we’re going to detail several tactics that you can use to fight back against this practice and prove that the findings were incorrect, biased, or wrongly interpreted.
Ways to Prove Your IME-Based Denial Was Wrong

Make sure you get the doctor’s opinion. Insurance companies have a way of picking and choosing the parts of a treating physician’s report to further the argument that they can stop paying you benefits. One way to curb their ability to do this is to make sure that the doctor offers his or her expert opinion on your disability in addition to the rote facts uncovered in the exam.

Last time, we went over several methods that insurance companies use to try to deny long term disability benefits to people who hold “own occupation” policies with them. We talked about misrepresentation, where insurers basically try to prove that you lied or made mistakes on your application so that they can cancel your policy – even if you’ve been paying for it for decades. We described how they’re now forcing people to provide “objective” evidence (i.e. your doctor’s expert opinion isn’t good enough; your problem needs to show up on something like an MRI test or it’s not “proven”). And we warned you about doing any kind of work outside of your primary occupation, because insurers will latch on to this and argue that they can deny your claim because you really have two occupations.

Below you’ll find several more shady tactics that they use.