Tips on Disability Insurance Claims|
by United Policyholders
1. BEFORE YOU MAKE
A CLAIM: READ YOUR POLICY AND REVIEW YOUR APPLICATION.
2. YOU MAY NOT BE
ABLE TO COLLECT BENEFITS DURING AN INITIAL ELIMINATION PERIOD.
- Read the definition
of disability in your policy to determine whether or not your condition
qualifies for benefits.
- Have your treating
doctor confirm and explain your disability in writing to the insurance
company. Almost all policies require that you be under continuing care
by a doctor to qualify for disability benefits.
- Review the answers
you gave on your application. Are they true? Will they conflict with
the medical records that your insurance company will obtain?
Be sure that if you answered any of the questions incorrectly you have
a good explanation. If there is an inconsistency between your application
and your medical history as reflected in your doctor's records, it is
often because you misunderstood a question on an application, or, your
agent told you the insurance company was not interested in minor problems,
or, you did not know, at the time you filled out or signed to the truth
of your answers that you had a condition that would have required a
different answer. If so, be prepared to explain the inconsistency to
your insurer during the claims process.
policies contain an elimination period that requires you to be disabled
for a certain period of time before you can collect benefits. The shorter
the elimination period, the more expensive the policy. It's like a deductible.
3. FILE A CLAIM
AS SOON AS YOU KNOW YOU ARE DISABLED.
matter if you won't be eligible for benefits for several months - file
your claim promptly upon discovering your disability. The insurance company
has the right to know that you are currently disabled and that you will
be applying for benefits. A failure to promptly submit a claim can result
in the insurance company denying your benefits. Don't give them the excuse
to do this.
4. CONFIRM COMMUNICATIONS
WITH THE COMPANY IN WRITING
to speak to the adjuster assigned to your claim over the phone but follow
up with a letter documenting whom you spoke to and what was said. When
you send notice of your claim to your insurance company make sure to send
it by registered mail, return receipt requested. Don't give them an excuse
to tell you that they never received notice of your claim or any other
important information that you want them to have.
5. KEEP A CLAIM
Keep a running
record of every phone conversation, in-person conversation, date, time,
name of person spoken to, etc. Write for as long as it takes to clearly
explain what transpired. You may think you will remember, but little details
can be really important later on and are easily forgotten when you are
the right to tape record in-person meetings, telephone conversations,
and/or insurance company scheduled doctor appointments. Just make
sure to tell the adjuster that you are going to do so.
COMMON QUESTIONS AND ANSWERS:
IF I CAN NO LONGER
WORK AT MY CURRENT JOB, AM I ENTITLED TO BENEFITS IF I CAN BE TRAINED
FOR ANOTHER JOB?
on your policy. Many policies specifically cover you for the job you had
when you became insured. These are known as "own occupation" policies.
If you have one of these policies and you become disabled and cannot do
your job; you can collect benefits even if there are other types of jobs
your disability would allow you to do.
Under an "own occupation"
policy, for example, if you could no longer do your job as a violinist
with a symphony due to a disabling wrist injury, you would be entitled
to benefits even if your disability would not prevent you from working
in the box office collecting tickets. Under an "any occupation" policy,
the answer would be different. (See below). That's
why it's so important to read your policy and know your rights. Some policies
will insure you for your own occupation for a specific period of time.
After that time elapses, you will only be paid your benefits if you are
disabled for other work as well.
IF I DO NOT HAVE
AN "OWN-OCCUPATION" POLICY, WHAT IS THE DEFINITION OF TOTAL DISABILITY?
of "total disability" varies from state to state and policy to policy.
In California, total disability is the inability to perform with reasonable
continuity an occupation for which you might reasonably be expected to
engage in view of your station in life and your physical and mental capacity.
In other words, if you are a schoolteacher, the insurance company cannot
deny you your benefits because you might be able to work at a fast food
DO I HAVE TO KEEP
PAYING PREMIUMS TO KEEP MY DISABILITY INSURANCE POLICY IN FORCE WHILE
not, under what is called the "premium waiver" provision in most policies.
The answer depends on the wording of your policy. Read your policy. Know
your rights. Do not run the risk of letting your policy lapse, (i.e. be
canceled for non-payment), because you think you might not have to pay
your premiums. When in doubt, pay your premium. Your insurance company
is required to refund any premiums you paid while you were disabled if
that is provided in the policy.
WHAT IF THE INSURANCE
COMPANY TERMINATES MY BENEFITS WHILE I'M STILL DISABLED?
doctor to provide your insurance company with written documentation of
your continuing disability. Then ask your insurance company to respond
in writing to your request for reconsideration. If the insurer still refuses
to reinstate your benefits, consult an insurance law expert.
WHAT IF THE INSURANCE
COMPANY ASKS FOR COPIES OF MY TAX RETURNS?
Do not simply
turn over your income tax forms just because they ask for them. You have
a constitutionally protected right of privacy. Moreover, your tax returns
should be irrelevant when you are applying for disability. All that matters
is the amount of the benefits stated on your policy and the fact that
you were working full time at the time you became disabled. It doesn't
matter how much money you were making. Don't complete and sign IRS Form
4560. This will grant the insurer free access to your tax returns.
HOW SHOULD I FILL
OUT THE CLAIM FORM?
best you can, be honest, of course, and if you are unsure about something,
indicate "undetermined". When you list the material and substantial duties
of your occupation on your claim form be specific. If, for instance, you
do administrative work only 5% of the time make sure the insurance company
CAN I STOP PAYING
PREMIUMS EVEN IF MY CLAIM IS DENIED?
the premium with a check and note "contested payment" on the check or
in a letter accompanying the payment that explains that you are paying
under protest because your disability entitles you to a premium waiver.
But don't stop paying your premiums or the insurer will have an excuse
to cancel your policy.
I'VE HEARD OF INSURANCE
COMPANIES SURREPTITIOUSLY VIDEOTAPING PEOPLE. DOES THAT REALLY HAPPEN?
aware that if you file a disability claim, you could be videotaped by
the insurance company when you unaware. The purpose is to record you doing
some activity you claim you are unable to do. In a well-known case, a
policyholder that claimed to have a disabling back injury was captured
on tape on fast-moving rides at an amusement park. Insurance fraud is
costly for all of us and allows insurers to justify privacy invasions
such as surreptitious videotapes. Don't give them an excuse to deny your
claim by exaggerating your disability.
IF THE INSURANCE
COMPANY IS WEARING ME DOWN, SHOULD I OFFER TO COMPROMISE BY ACCEPTING
LESS BENEFITS THAN I'M ENTITLED TO?
your ground and don't give up! You are entitled to the full benefits
you paid premiums for. You have kept your end of the agreement by paying
your premiums and the insurer should honor their part of the agreement
and pay your claim. Don't give up your rights! Don't agree to
or sign anything without knowing your rights. Seek counsel
whether it is an attorney, your insurance agent, or the Department of
Insurance. Leave no stone unturned. Fight for your rights. Use your telephone
book and local agencies to get help.
There are no dumb
questions. If you don't understand something, keep asking questions
until you are satisfied with the answers. You won't know if you don't
ask. Take care of business--don't put things off when it comes to your
claim. Address issues as they come up. If you don't take control, the
insurer will, and their interests are not the same as yours.
UP thanks Alice Wolfson,
Esq. of Bourhis, Wolfson and Schlictmann, Amy Bach, Esq. of the Law Office
of Amy Bach, and policyholder Katherine Sanchez for assistance in preparing
this Tip Sheet.
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presented in this Site is for general informational purposes, and should
not be taken as legal advice. If you have a specific legal issue or problem,
United Policyholders recommends that you consult with an attorney. United
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