So many insureds with disability claims are pulling Plans and policies from aging boxes in their attics and are attempting to make sense of what they say. Unfortunately, insurance policies have never been known to be “self-explanatory” and therefore there are many misrepresentations that are leading people astray. Let me give you an example.
Recently I received a call from a woman who worked for the same employer since 2004. She filed for disability in 2019 after her company changed from one group insurer to the next in 2014. After reviewing her Plan she called me in a panic with fears of pre-existing conditions, scared her insurer would investigate what medications she took, or what treatment she received in the past, and on and on.
After questioning her a bit more I asked, “Where the heck are you getting this stuff from?”, to which she replied, “Well, my policy does say if I took prescribed medications or received treatments in the past they could deny my benefits.”
Good grief. I guess she missed the part about pre-ex that says, “If you go out on disability within 12 months of your effective date of coverage……” So, let’s see. She’s been with the same employer since 2004, AND the effective date of coverage for a new Plan was in 2014. Her date of disability is in 2019. How could there possibly be a pre-existing condition?
This woman was absolutely adamant about the pre-x issue and debated it with me for a few minutes. Finally, she saw the error of her review. This same woman also insisted that ERISA was involved with the management of her claim.
Well, let me tell you that the Employment Retirement Income Security Act of 1974 (ERISA) has absolutely nothing to do with the management of claims. ERISA does set up time limits for appeals etc., but then again, no regulator is enforcing timelines. ERISA comes into play when claims are denied and litigated – ERISA is “no help” for preventing claims from being denied.
Just try to tell an IDI insured physician that his “better than sliced bread” IDI own occupation policy isn’t what he thinks it is. His agent also sold him a Residual Rider and now he has TWO definitions of disability in his policy. Sometimes I never can convince IDI insureds that they got 
when they bought IDI own occupation policies with residual provisions. It just isn’t so that all insureds can work at other occupations and get paid 100% for total disability.
There is enough misinformation out there to guarantee the demise of many disability claims. My recommendation is to begin 2020 with a new outlook toward filing and managing disability claims, walking carefully and obtaining accurate information before falling off the cliff.
If you call me with misinformation I’ll probably ask you, “Where the heck did you get that from?”, before giving you the real scoop.
