Disability Claims Solutions

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When inureds ask me, “How can my insurance company deny me when my physician says I can’t work?”, I always think of the explanation of the difference between “truth and perception.” Disability insurance companies ALWAYS operate off of PERCEPTION, not truth, therefore what is perceived from information takes precedence over what is actually true.

For example, a three-day surveillance report indicates insured X walked around the local Mall with her grandchildren for 3 hours. The insurance company perceives that if the insured has the physical stamina to do that, she can also work a sedentary job. The truth is completely different – walking around the Mall is not an indication of full-time work capacity and none of her treating physicians have released her to return to work.

Insurance companies often “perceive” situations because they do not have direct access physically to insureds and must take a doctor’s word for it that he/she is unable to work. To begin, every insurance company perceives that physicians ADVOCATE for their patients and OVER RESTRICT them from working in nearly every instance. The TRUTH is that most physicians are reluctant to certify someone as “disabled” because they know it will all come back to them if they are proven wrong.

A characteristic of disability insurers is that they will never accept a set of FACTS and use them as accurate, but prefer instead to operate off of their own perceptions given by physicians and others who have access only to “paper medical reports and patient notes.”

In reality the opinion of a physician who actually examines and has face to face contact with insureds should be more credible than reports and opinions rendered from patient notes. Still, we have to keep in mind who the boss is here. Insurers can use or reject any information they want to leaving them only with “perceptions” to make decisions from.

Many years ago the “Physician’s Treatment Rule” gave deference to his/her opinions over all others, but the insurance lobby destroyed the rule through the courts. Now, insurers have discretionary authority to decide for themselves who gets paid and who doesn’t with full federal governmental support through ERISA laws.

I know this is true by the preponderance of insurance medical reviews I’ve read that almost sound like insurers have mixed up insureds and are reporting about someone else. It’s almost as though insurance reviewers say to themselves, “Let’s review these facts and see what we can perceive that is favorable to us.” Prudential is a masterfully clever company that can take any set of facts and “misrepresent” every fact in the record with a misguided perception. Unum is actually second to Prudential in “perceptive misrepresentation.”

When insureds speak to claims handlers on the phone as representatives of the insurance industry they “read through your words”, selectively choosing to document conversations in their own favor. What you write in letters is cited back to you backwards and misrepresented. Insureds always want to trust and believe in what they are told, but the unfortunate truth is, insurance companies form their own opinions by “perceiving” what THEY think is true instead of actually what IS true.

Of course, it’s to their advantage to do that. It’s very easy to render a denial decision when the only opinions considered belong to biased parties such as insurance companies. In addition, it’s very difficult in today’s terms to defend against a “negative” when it’s unclear to insureds what they need to do.

Disability insurance review procedures are now designed to develop perceptions from paperwork reviews and accept them as fact. My job as a Consultant is to resolve problems by reversing negative perceptions. The way to do that is with a preponderance of fact that overrides perception and opinion.

The important thing is for insureds to understand the difference between use of FACT vs. PERCEPTION in the claims review process and realize where the real conflicts are.