ADLs     Claimant Bill Of Rights

As a direct or indirect party to a legal contract involving insurance coverage for group disability or income replacement, you are entitled to legal and contractual rights of expectation that the provisions agreed to are adjudicated in a fair, unbiased and equitable manner by the disability insurer.

  1. You have the right of full disclosure. As the insured party to a disability contract you have the right to receive and examine all collected data, both paper and electronic, collected by the disability insurer in the process of reviewing your claim for benefits. This includes all administrative and chronological records, conversations, meetings, data base checks, field surveillance, and any other data affecting your privacy as an individual. This information must have been used by the insurance company to deny your claim for benefits. Under ERISA regulations you have the right to receive a copy of your policy and claim file within 30 days of requesting it. If it has not been provided to you within the designated time frame, the insurance company may be fined $110 per day.
  2. You have the right to privacy and respect. You have the right to expect medical records and any other private information which reflects upon your credibility, integrity or reputation, to be kept private and treated with respect. You have the right to know what type of information is requested over and above that which is needed in making a fair decision on your claim. You have the right to know when your claim is being reviewed in a public forum and by whom. (Such a roundtables.) You also have the right to know the name and title of the person who will actually be making the decisions on your claim. Quite often, it is not the claims specialist who does this.
  3. You have the right to a timely claim decision. You have the right to expect your disability insurer will make every effort to render a claims decision within 30 days (ERISA claims) or that period of time indicated in the policy provisions and state statutes. You have the right to be notified in writing every 30-45 days as to the reason why your claim decision is delayed. ERISA regulations require the insurance company to keep you informed by sending “tolling letters” if the claim decision is not make within the 30-45 day period.
  4. You have the right to a fair and objective claim review.You have the fiduciary right to expect your disability insurer will make every effort to consider ALL recommendations and opinions given to the insurer by your primary care physicians, consultants, counselors, and any other specialist who is qualified to render an opinion concerning your ability to work. (ERISA claims or industry standards if an Individual Disability policy) You have the right to expect the disability insurer will consider the experience and qualifications of your doctor as equal to those of its own in-house physicians, and to make fair and honest attempts to reconcile professional differences of opinion.
  5. You have the right to fair representation of facts. As the insured you have the right to a clear understanding as to the party or parties responsible for making the liability decision for your claim. You have the right to know who is authoring communications to you from your insurer, and the names of all employees, consultants, directors, and others who are offering medical or administrative opinions concerning the facts of your claim. You also have the right to expect honest communications concerning the meaning and presentation of all policy provisions.
  6. You have the right to withhold authorization of release of information which is overly broad.Any individual has the right to retain privacy rights to information without fear of loss of benefits. It is your right not to sign Authorizations of Release which are overly broad, or, which allows the disability insurer to obtain information outside of what is required for a fair and objective review of your claim within the provisions of your policy. Many of the newer ERISA disability policies contain provisions which require you to sign an Authorization and cooperate with the insurance company or risk loss of benefits. You have the right to designate any or all actual patient and psychotherapy notes as Protected Health Information under HIPAA. Once these records are released, they lose submission protection under HIPAA.
  7. You have the right to choose appropriate medical treatment without threat of termination of claim. You and your physician have the right to choose medical treatment which is appropriate to your medical condition without having any insurance company threaten to deny benefits if you do not “do what they say.” Medical treatment is an issue between the insured and his/her medical treatment providers only.
  8. You have the right to ask questions. As an individual outside of the specialty of the insurance industry, or understanding of that industry, you have the right to knowledge, explanation, definition, instruction and full understanding of the provisions of your policy without fear of loss of benefits.  You have the right to ask questions concerning your claim as often as is necessary for your understanding of the facts without fear of retaliation, suspicion, or unfair investigation tactics.
  9. You have the right to ethical conduct. As an insured you have the right to expect your disability insurer, and its representative employees act in “good faith.” You have the right as an employee or policyholder to expect your insurance company creates and maintains a clearly defined disability claims review process which lends toward the fair, objective and timely, review of all claims submitted as part of its product business.  You have the right to expect your insurance company have in place a process which routinely and consistently corrects flaws within the review process; recruits, trains and retains individuals qualified to review disability claims; and provides a forum for independent appeal processes.
  10. You have the right of non-discrimination. All insured have the right to expect their insurance company not discriminate on the basis of indemnity amount,  self-reported or physical impairment, education, training or experience, occupation, age, sex,  mental and nervous disorder. Policyholder, geographical region, claim location, event, physician, claim duration, months of paid benefits, or any other target objective identified by management. You have the right of expectation that your claim will not be targeted by management for denial as a “block of business” due to any of the above.
  11. You have the right of appeal. As an insured covered under the Employment Retirement Security Act of 1974 (ERISA) you have the legal right to a timely independent appeal review of your claim. For non-ERISA individual disability claims, you have the right to report discrepancies to your state authorities and to retain legal counsel, and request “reconsideration” of the denial decision.

This “Bill of Rights” was written by Linda Nee, a Disability Claims Consultant. Although there is no law or regulation upholding these rights as an official document, the rights described here are reasonable and should be expected from any disability insurer with a duty to uphold generally accepted industry standards to review claims objectively, with good faith and fair dealing, and without bias or financial prejudice. Insist upon being treated fairly and with respect!