Over the years I’ve written many articles about restrictions and limitations and what can happen if an insurance company observes, and records, insureds exceeding restrictions, thereby demonstrating work capacity.
As always, some insureds receive what I say seriously, others do not, taking the value of their claims into their own hands, sometimes with very expensive consequences. Some of you may not appreciate what I am about to write, but I do it with the utmost sincere intention of concern for you and your claim.
I’m not sure what causes a highly paid professional with a monthly disability benefit of $20,000 to go zip lining, horseback riding and mountain climbing. It is especially hard for me to understand, when this same individual decries neck and back problems to an insurance company. If the tenets of Murphy’s law are correct, it is possible for an insurer to observe the above activities on just the right day and time. If this happens, the claim is lost!
Filing a disability claim is serious business. Essentially, one party to the Plan or contract informs an insurance company he/she is unable to work due to medical impairments(s). If this is NOT true, and a person files anyway, they are committing fraud. If later, a physician documents medical restrictions and limitations based on what patients say, and it is not true, the insured is committing fraud. Another accusation can be also be made that the individual is “malingering”, meaning false reasons are given for not working due to laziness or just not wanting to return to work. Highly paid (claim) insureds can also be accused of filing claims for “secondary gain”, meaning filing a claim just to profit from the money.
One of the top questions I am always asked is if an insured can play golf. On occasion, even a client will be seen mountain climbing, skiing, or riding dirt bikes. Sometimes, I just don’t know what people are thinking because when they have a disability claim, they are considered at least to some extent to be disabled, AND ARE EXPECTED TO ACT DISABLED. It is not part of the process to file disability claims and then just go about doing the same activities you always did.
I don’t get the rationale of risking sometimes $10,000/month+ in benefits to engage in physical activities that risk that kind of income. What I do understand as a Consultant is that when a physician documents medical restrictions and limitations insureds are not expected to EXCEED those restrictions under any circumstances. If they are later observed by the insurance company performing activities proving work capacity far beyond what has been reported, then claims should be denied and I would support that.
Again, filing disability claims is not a game. The idea of someone with documented back and neck problems riding a horse astounds me. If a horse is rode correctly, one uses their legs to push up and then the entire spinal column comes down on the seat – not a great activity for someone with neck and back problems. I don’t get it, I really don’t.
Additionally, the idea that some insureds have that they can get away with these activities sight unseen usually comes back to bit them. For example, an ex-spouse, neighbor, or ex-employee calling up the insurance company and reporting the horse back riding. Oops!
Let’s not underestimate insurance companies, they have their ways of finding out things. Perhaps an insured takes his son to Maine and zip lines all over the mountains, and then his son brags about it on his Facebook page, complete with with pictures. Gotcha, again! Maybe the ex-spouse, after listening to his/her son describe all the nice things they did, decides to call Unum. What then?
Sometimes insureds offer the weakest of excuses when they get caught by insurers. “Well, I suffered for it, I can tell ya, for about two weeks.” Insurance companies do not care about that! If they observe you demonstrating work capacity one time, your claim is gone. This is not something you can just explain away, such as, “I was only on a pony with my son, not a horse.”
Surveillance, cannot be explained away because “seeing is believing”, particularly in front of jury. Those insureds with $20,000+ benefits may think their attorneys can make a good case and get them out of it, but what is ultimately gained is usually a meager settlement. Why are you taking such a risk at losing your benefits?
This Consultant supports the adherence to medical restrictions and limitations provided by treating physicians for the protection, health and safety of a disabled person. No one on claim should be exceeding those medical restrictions any time, Once observed by an insurer, there is no excuse for the demonstrated work capacity.
I apologize in advance if I’ve offended anyone, but when you are on disability there are some things you just don’t do. Whatever medical medical restrictions and limitations are reported to insurers, you are. in essence saying you do not have the mental or physical capacity to work.
When you step out of that box and demonstrate you DO have the ability to work by performance of any activity, then you are no longer disabled and should NOT have a disability claim.
I could probably write 10 additional articles about how disability insurers abuse surveillance and misrepresent work capacity. I’m not writing about them right now, and what insurers do is not an excuse for what you do. As a Consultant, I support what is truthful, factual, accurate and honest.
Do you think that insurers are not out there more so than ever when half the country is filing claims for COVID? Please take what I am saying seriously and insure that what you and your doctor are documenting for medical restrictions and limitations is the truth, and that you are abiding by those instructions at all times.
The risk just isn’t worth it. A $10,000+/month benefit is a lot of money to me, and I just don’t get the rationale of putting it at risk. More than that, it’s just not right from a claims perspective, and I don’t support it.