If you are disabled, you will have many concerns – health, recovery, impact on family and career, and finances. It probably goes without saying, but because becoming disabled is a huge and unpleasant surprise, you may be in shock and not thinking clearly. In filing a disability insurance claim, you don’t want to make innocent mistakes that might harm your ability to collect on a legitimate claim for insurance benefits. Here are suggestions that may help the claims process go more smoothly.
If you are disabled, get in touch with your agent. The agent will help you get the claim forms from the insurance company.
Your agent can’t speak for, or make decisions on behalf of the insurance company, and your agent can’t and shouldn’t complete the claim form for you.
Since there are an infinite number of job descriptions and medical conditions, THESE REMARKS ARE OF A GENERAL NATURE.
The essence of a disability claim is that due to a medical condition you are unable to do your job. The existence alone of a medical condition is NOT a disability insurance claim.
When filing a disability claim, you are asking the insurer to give you money based on the words in the policy. Before completing forms, you must READ YOUR POLICY! For example, you must know what they mean by “Total Disability”, “Residual Disability”, and “Partial Disability”. You must know how they define “your job”. For example, the policy might say “your job” means “the job or jobs you are doing at the time of becoming disabled”.
You and your doctor complete the claim form. You provide details on the duties of your job, and the doctor will answer the questions about your health.
It is extremely important that your doctor know the exact nature of your job. If your doctor does not know exactly what you do on a day-to-day and hour-to-hour basis, how can she accurately complete a form about your ability to do that job?
Some claims are very clear-cut, but often, it will be helpful if your doctor has a copy of the definitions of disability before she completes the form. You may even want to be there when the doctor completes the claim form in case she is unclear about something.
Do not fill in the doctor’s part of the claim form, then ask the doctor to sign. The “attending physician” section is not for your interpretation of your health but is for the doctor’s.
After submitting the claim form, you will be contacted by a claims representative from the insurer. It will be helpful to you on many levels if you keep a positive, cooperative relationship with this person. For example, he may ask for follow-up information. It may seem annoying and unnecessary, but you will benefit by complying. Don’t assume the claims person is your “buddy”, but there is no reason to antagonize him. Conversations with the claims person will also give him a sense of how keen you are to return to work – a good thing from their point of view.
In some cases, the claims person will want to meet you in person. That is standard procedure. Or, the claims person may drop-in on you because they are “in the neighborhood”. You may want to decline the drop-in visit if you aren’t up to it and suggest a scheduled meeting on another day.
Because insurance companies are burned every day by fraudulent claims, claims examiners are trained to try to determine if a claimant is just looking for a free ride. Don’t take that personally. It is just a fact of life in the insurance business. On the other hand, many claims are paid without the insurer requesting all the information they legitimately could have, because the claim was clear-cut.
If a claim looks like it’s stalling, it could be damaging to a constructive solution if you threaten legal action. A good insurance agent should be able to help you determine what is needed to get the conversation back on the rails. Disability insurance claims do occasionally reach the stage where lawyers are involved, and you clearly have the right to consult with your lawyer. Experienced disability insurance advisors suggest an amicable relationship with the claims person will yield better results, certainly in the early stages. The claims representative generally doesn’t care if there’s legal involvement – it’s not their problem – so in many cases, a legal threat too soon will close any opportunity for you to get the benefit of the doubt. Clearly, this is a highly subjective area, and you should speak with your legal advisors about your options.
A claim generally has two components: A medical condition, and a loss of income. “Loss of income” is sometimes not a factor with a “total disability” claim but is for a “partial” or “residual” disability. “Loss of income” is sometimes hard to measure, depending upon the nature of the disabled person’s business or practice. Insurers know that every business is different, therefore the best thing is to discuss with the claims person the exact nature of your business, job or practice. Authorizing your accountant to speak to the insurer is another efficient way of communicating financial information. The insurance company will likely ask for financial information going back five years. That is normal, and is needed when calculating any “Partial” or “Residual” benefits.
After some time has passed, a medical condition might not require ongoing medical supervision. In some disability policies, discontinuing medical treatment can be a reason for the insurer to stop paying the claim. Check in advance and speak with your doctor to develop a strategy to reassure the insurance company that, even though there is no ongoing medical care, there is an ongoing medical condition.
Depending upon the nature of your disability, the insurance company from time-to-time, will ask for an update on your condition.
If your health allows you to do some of your job, but not go back to work “fulltime” or at “full income”, you might qualify for “Residual” or “Partial” disability benefits. Again, refer back to the definitions in the policy as you self-monitor your situation.
Generally, if you are medically “able” to return to work, the disability insurance claim stops (or becomes a “Partial” or “Residual” claim).
It is not enough to continue a claim because you are unable to find a job, unable to work with co-workers, feel a negative work environment might stress you, want a bridge to retirement, or are concerned about contracting a medical condition because of working.
For example, some heart attack patients have difficulty returning to work for fear that the stress of the job may promote a second heart attack. Unless there is damage to their heart as a result of the heart attack that limits the ability to work, there is no claim payable for “prevention” of the next heart attack.
If your health recovers and you are “able” to work, a misconception is that the insurance company has to find you a paying job, and if there isn’t a job out there to go to, you are still “disabled”. Not so. The disability policy pays based on your health and ability to work, not on the job market.
The disability insurance contract is between you and the insurance company. Generally, your agent can help clear up any communication issues or investigate if you feel there is an unnecessary delay in the process. Your agent should be able to help answer any questions you have about the wording in your policy. It will be the agent’s opinion, and not binding on the insurance company, but hopefully will clarify things for you.
PLEASE NOTE: The comments and references to policy wording above are of a general nature, are “in my words”, and do not refer to any specific policy. The actual contractual wording will be found in your insurance policy documents.