All IDI Claims Are “Pending” Month To Month
More and more insureds with older Individual Disability Income Protection polices are finding themselves in trouble attempting to fight IME requests. Cited defenses include the wording, “…we may request an IME while the claim is pending.” General misunderstandings of the policy provisions often causes IDI insureds more trouble than they really want.
Some of the most adamant protestors are insurance agents who under write their own policies and take the provisions to mean that once a claim is approved there is no longer any requirement to submit to an IME. WRONG!
IDI claims are “pending” every month. Remember, there are provisions that say, “…must submit proof of claim within 90 days for any claimed period of disability.” This means that claims cannot be denied for “failure to provide” until 90 days after a period of disability. This provision also means that IDI claims are “pending” every month and are approved and paid month by month.
What is interesting is that IDI claims are paid every month and insurers do ask for proof of claim within 30-45 days of their requests. However, no denials for “failure to provide” can take place until there is no proof after 90 days. Insurers find it easier to compare “apples to apples” administratively, but policy language is what it is and no denial for failure to provide can take place prior to 90 days.
Some “one french fry short of a Happy Meal” claims handlers don’t get it and threaten denial if update documentation isn’t received within 30 days. And…frankly, some insureds don’t get it either.
For example, if your first benefit begin date is January 1st, and you want to get paid for that month, proof of claim, according to the policy, must be received by March 1. February’s benefit requires proof of claim by April 1st and so on.
To be clear, if you want to get paid for January in February (benefits are always payable retroactively) then you should submit proof in 30 days – even though the claim cannot be denied for failure to provide until the 90 days have elapsed.
If claims are pending each month, then an IME can be requested at any time throughout the history of the claim. The policy language uses the word “pending” and it confuses some insureds who choose to go to battle claiming there is no contractual obligation to submit to an IME once claims are approved.
Claims can be denied or suspended for failure to submit to an Independent Medical Evaluation even when the contract uses the terms, “…while the claim is pending.” IDI claims are pending month to month.