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complacencyThe definition of “complacency” taken from the Webster Dictionary is: self-satisfaction especially when accompanied by unawareness of actual dangers or deficiencies.’ “If I don’t challenge my insurance company or make waves, everything will be fine, and I’ll never have to worry.”

As a Consultant, I am always surprised at the number of insureds who believe that if they just provide their insurance companies with every piece of information they can think of, claims will continue to be paid. “I don’t want to make waves with my insurer, they will get mad at me!” I hear this statement all the time, and it’s never true.

Employer Group ERISA Plans are adversarial to claimants from the time of initial enrollment to filing claims. These Plans are contracts between insurers and employers. Claimants are called “beneficiaries” or “participants”, and have nothing to say about the writing of the Plan or the provisions the Plan contains.

Therefore, coming out the gate, ERISA Plans are referred to as “contracts of adhesion” and deference is supposed to be given by judges to claimants for that reason, although in today’s ERISA litigation culture that does not seem to happen. In combination with “discretionary authority” claimants have no influence on liability determinations and remain completely unaware of the dangers of providing insurers with enough data ammunition to kill claims.

The truth is, claimants/insureds cannot TALK THEMSELVES into receiving benefits, nor can they COOPERATE enough to ensure future benefits.  The idea that if you just “tell insurers what they want”, “provide what they want”, “be nice”, “believe everything they tell you”, “be fearful”, “cooperate with the process even when it is out of contract”, and “never defend your rights” ensures future benefits is absurd. Really absurd.

In my experience, quite often attorney clients are the worst because they think they can “negotiate” everything. Although settlements can somewhat be negotiated, there is nothing about a disability contract or claim that is “negotiable” since insurers will enforce their own interpretation of Plans and contracts as they see fit.

My point is, however, that there are many claimants and insureds who actually believe if they do everything insurers ask them to do, they will have a paid claim. While insureds might “hope” this is true, it rarely is.

Here are the tope 10 situations insureds and claimants might want to challenge instead of just giving in to insurers.

  1. Insurer gives your doctor 1 week to provide records when your Plan/policy says 45/90 days.
  2. Threatening or forcing claimants to sign SSDI Authorizations to obtain files.
  3. Insurer positioning field visits as mandatory when there are no provisions in the Plan/policy requiring you to meet with field representatives.
  4. Agreeing to an offset repayment plan when no proof has been provided to you of what you actually owe.
  5. Surveillance resulting in a “private trespass”, such as banging on your door or entering private property.
  6. Statement by insurer that medical records must come directly from physician’s office. ERISA Plans specifically state all proof is to be provided by the claimant and at the claimant’s expense.
  7. Must speak to claims reps on the phone. No Plan or policy requires claimants/insureds to speak on the phone. Claimants ARE required to provide answers to questions, but are not required to do so on the phone spontaneously.
  8. Insurer informs you CPT/CDT codes must be provided in a particular format of their choosing.
  9. Misrepresentation of policy provisions. Contract language cited in a letter is not what is in your policy.
  10. Forcing you under threat of claim denial to apply for SSDI when you have plans to return to work within 24 months.

It is a well-known fact that some insureds are more inclined to say anything, do anything, and provide anything if they think by doing so claims will be paid. It is also true that of those claims that are denied most are backed up by information and phone conversations insureds themselves provided. Claimants/Insureds who defend their claims and policies are generally paid for longer periods of time.

And, like the person sitting in the middle of a railroad track thinking everything is OK, in reality it isn’t. Over done cooperation never has, and never will guarantee continued payment of a disability claim.