Guidelines For Claimants

Long Term Disability Insurance Claims Guidelines

This information is provided by the Law Office of Justin Frankel to serve as a guide to help you navigate the complex hurdles of the insurance claims process. It is not, nor is it intended to be, a substitute for legal advice. Please be aware that every situation is different, and only by retaining counsel do you fully protect your rights.

If you have questions about the insurance process, please call our office at 888-583-4959. The more informed you are, the better.

Sorry, we do not handle SSDI/Social Security claims.

1 – Locate the original and any subsequent copies of your policy. Maintaining good records of your contracts will be highly useful, should you need to go through an administrative appeal or litigation. Do not rely on your employer’s HR department or insurance broker to have your contracts.

2 – Don’t go it alone. Working with an experienced professional who understands the complexity of the policies could mean the difference between a properly prepared claim and one that gets tied up in insurance company doublespeak, or worse, gets denied.

3 – Watch the relevant dates and deadlines carefully. If your policy requires a 60 day filing of proof of loss, make every effort to be several days or even weeks ahead of the curve. Filing even a day late could turn a solid claim into a denial.

4 – Your medical records are an important part of your claim presentation. You have a right to have a copy of all of your tests, records and reports and you need time to review them. If there are things you don’t understand – ask your doctor. If you still don’t understand, keep asking. If your doctor or the office doesn’t cooperate, don’t be intimidated – ask a trusted friend or professional to help. If there is information that does not seem right to you, insist on discussing it and when appropriate, request that corrections be made in the proper manner.

5 – Your doctor(s) are not insurance professionals and may not understand the nuances that dictate so much in determining claim decisions. Your records must clearly indicate limitations and restrictions that relate specifically to your occupation and very clearly describe how these problems prevent you from performing the tasks necessary to do your job.

6 – Your medical records must include documentation that could also serve as evidence of your inability to perform the necessary tasks associated with your job, whether it is physical labor or pure brainwork. Insurers tend to intentionally fail to consider the cognitive requirements of work, so you must be vigilant to present those aspects of the job.

7 – Every time you have contact with the insurance company and/or its agents, be careful. Have a pad and pencil and take detailed and legible notes on who you spoke with, the date and the details of the conversation. If you are unable to do this, have a trusted friend or professional on the phone or in the room who can serve as a witness on your behalf. Tell the insurance company representative if another person is on the phone line with you, and make a note that this has been made clear to all parties. After each phone conversation, send a letter by registered mail that describes the conversation and all of the details. Request that the insurance company respond if there is any difference of opinion as to the conversation or the details.

8 – Protect your claim. No matter how sympathetic and friendly the insurance company representative may be, they are not your friends – and their job security, bonus or career advancement may depend on how many claim denials or delays they can rack up.

9 – Filing a disability insurance claim immediately opens the possibility of surveillance and investigation. If your claim involves being unable to travel to get to work, you may be videotaped if an investigator sees you driving or travelling. If you call the insurance company from a phone not located in your home, Caller ID records can be used to prove that you are able to travel. Think like an adversary. BE CYNICAL.

10 – Keep your claim, your disability and the claims process private. Today’s insurance company watches public posts, forums, bulletin boards, chat rooms, social networking sites, and any online source where information could be gathered.

11 – The claims process is a minefield. Filling out forms is equivalent to an attorney preparing for trial – every piece of information is a chance to build or destroy your claim. Be 100% honest, but do not leave yourself exposed to evidence contrary to what you have stated. If you have days where you are fine, be prepared to state how many days a week you are able to function. If your disability leaves you unable to do much of anything except between 1 – 2 PM, say so. If the forms are not long enough or you need additional space for more details, make a note on the form that clearly indicates that more information is on the attached page.

12 – If the insurance company tells you to go for an IME (Independent Medical Examination) understand that you are going to be examined by a doctor who is NOT independent – he or she is paid by the insurance company or a third party administrator.

13 – If you are ordered to go to an FCE (Functional Capacity Evaluation), review your policy line by line to determine if this test is specifically in the language of the policy. These tests are not necessarily required, and they can be dangerous. If you go for the test and you are asked to perform a task that you know you cannot do without pain or discomfort, say no. Be sure to document how you feel following the testing, and consider seeing your treating doctor shortly after the testing for a further evaluation.

If you have any questions or would like to speak with Justin Frankel, please call our office at 888-583-4959 or click here.