I know there are a lot of insureds out there who seem to think they have to “do what they’re told” even when requests from their insurers are unreasonable and unfair. However, people should learn to draw the line somewhere and be able to defend their Plans and policies in accordance with what’s written in them.
If you are just such an insured, you need to develop alternative financial planning because those who refuse to defend what’s right usually lose their benefits in the long run. I am constantly advising clients to put certain things in the record, which could change the future course of a claim.
Frequent Requests for Information
Although insurance companies can request information relative to your claim any time they want to, there is a standard of reasonableness that should be met. For example, insurers often take way to long to review information sent to them; therefore, when they get it back, it’s always old news and they send out another letter requesting an update and payment decisions are stalled. The problem with this is that benefits can be permanently delayed, along with liability decisions, while the insurer takes its time to review what it does have, over and over again.
In nearly every instance with insureds I speak to they are reluctant “to call a thing a thing.” In other words in the example given, the insured. needs to provide a letter stating: “Please be advised that it is an unfair claims practice to continue untimely medical reviews that ultimately result in new requests for updated information. I am noting for the record my request that [ your insurer] review the most recent medical information [or any other information] and make a timely decision.”
Any time an insurer continues to ask for the same information either from you or your physician it’s time to put something in the record. “Please note that this information was previously provided to [insurer} and has been confirmed received. I strongly suggest that you “look again” for the information before requesting the same information. In order to “assist” you I’ve attached the last records to this fax and request confirmation in writing only.”
In the last several years, insurers have been “stepping up” the time allowed to provide additional proof of claim, with 5-10 days the most common. ERISA Plans stipulate 30-45 days to provide proof of claim; and, this also includes your physicians. Five to ten day deadlines are unreasonable in the claims process and I always document, “Please refer to the policy [or Plan] provisions that allow 30-45 days to provide additional proof of claim. IDI insureds have 90 days after the end of a period for which benefits are requested.”
The culprits are often third party paper chasers such as Release Point, therefore, it it is important to document for the record when untimely requests are made.
More and more the importance of credentials is becoming more and more apparent. Therefore, insureds should request copies of all treating physician CVs and add them to your record. Sometimes it does come down to which physicians have the more prestigious credentials.
What is most important here is for insureds to realize, particularly for ERISA claims, that the more information placed in the record the better. Always document YOUR point of view and make sure it gets in the file.
Having said this, some people will go way overboard and start writing ten page narratives in defense of their claims. That is NOT what I’m talking about. Writing more than a paragraph to an insurance company is never a good thing. But, placing legitimate information in the file from time to time is essential within reason.