OK, I’ll say it! All IDI insurers abuse Injury (Accident) vs. Sickness provisions in IDI policies. Nearly all IDI policies distinguish between Injury and Sickness usually by paying sickness to age 65, and injury Lifetime benefits. While most IDI insureds often pay for Lifetime Sickness and Accident Riders, there are still insureds who continuously try to put a round peg into a square hole.
First of all, let me define the difference between a private disability “Injury or Accident”, and “Sickness. An injury or accident is defined as “an injury that occurred as a result of an unforeseen occurrence of a catastrophic event.” (My definition) A logical analysis might suggest, “were it not for the catastrophic event would the impairment exist?” If the answer is “No”, then it is likely the claim should be filed from the beginning as an “Injury” claim.
“Sickness” on the other hand is the, “gradual approach of a medical impairment that worsens over time, or exists because of an otherwise bodily disease that has progressed to the point of functional incapacity in some way.” (Also my definition)
For example, Chiropractor Jones is in the middle of a patient manipulation when he slips on the floor, falls and breaks his wrist. He presents in the Emergency Room, but finds he is unable to return to work due to his accident. This would be classified as an “Injury” claim. Next, assume that Chiropractor Jones notices that for the last month or so the connective tissue in his thumb and hands has worsened to the point that he’s lost strength and can no longer perform his patient manipulations. This would be a “Sickness” claim.
Insureds often do not realize that insurers are paying them under the “Sickness” provisions until they near age 65 and realize benefits are going to end soon. Then, it’s always a “backward heave ho’” in an effort to fit a “sickness” claim into “injury” even though there was no catastrophic event or sudden unforeseen accident that caused the insured to be unable to perform his own occupation.
In order to do this, insureds would need to go back to the original date of disability and provide records either from the Emergency Room, or timely treatment by a physician for what is documented in patient notes as an “accident.” Trying to do this is nearly impossible. “Injury” claims should be filed as “injury” claims from the very beginning. Unfortunately, they aren’t, mostly because they are “sickness” claims.
Having said the above, all insurers will attempt to reclassify legitimate injury claims to sickness in order to avoid paying Lifetime benefits. And, they will allow insurers to believe they have Lifetime benefits until just shortly before age 65 when a letter goes out informing benefits are going to end.
Then the panic begins….”Well, what if I get my doctor to say I was disabled from an accident?”, or, “One of my doctors documented I was “injured”, and, “I can always say I had an accident at work.” Now, we’re nearing crossing the line into insurance fraud.
Best advice is to make sure “Injury” claims are filed as such from the very beginning. Insure that treating physicians continually document the current disability resulted from an injury. Trying to go back and redefine the nature of a disability after long periods of time won’t be successful.
It’s the honest mistakers that will be victims of this sort of thing and that’s unfortunate. If your disability is the result of an injury, please make sure it’s filed that way to avoid any future misrepresentation by the insurance company.