As a direct or indirect party to a disability contract involving insurance coverage for disability or income replacement (IDI), you are entitled to generally recognized rights of expectation that the provisions agreed to in the Plan or policy contract are adjudicated in a fair, unbiased and equitable manner by disability insurers.This is a really good time to re-acquaint yourselves with your rights.
You have the right to full disclosure at the time of denial. As the insured party to a disability contract you have the right to receive and examine all collected data, both paper and electronic, collected by the disability insurer in the process of reviewing your claim for benefits. This includes all administrative and chronological records, conversations, meetings, data base checks, electronic website information, field surveillance, website investigation and Internet searches, and any other data affecting your privacy as an individual. This right exists due to ERISA disclosure rules allowing claimants to obtain copies of their Administrative Record within 30 days of requesting it. These rights should be explained to you in detail in any denial letter you receive.You also have the right to know while your claim is paid who is managing the claim, and who is making decisions.
You have the right to privacy and respect. You have the right to expect medical records and any other private information that reflects upon your credibility, integrity or reputation, to be kept private and communicated with respect and in accordance with HIPAA. You have the right to know what type of information is requested over and above that which is needed in making a fair decision on your claim. You have the right to know when your claim is reviewed in a public forum (roundtables), and by whom. You also have the right to know the name and title of the claims person who will actually be making decisions about your claim. Quite often, it is not the claims specialists who do this.
You have the right of self-representation. As the owner or certificate holder of the policy or Plan, you have the right to defend your policy or Plan in any manner you find appropriate. This means you may obtain information from the Internet, retain qualified experts to assist you, and communicate your concerns to any insurance company to defend your right to receive all benefits you are entitled to. Insureds and claimants may communicate with insurers over and above any “administrative assistance” retained in defense of their benefits and policy and they may obtain information from any source to assist with their claims.
You have the right to control the release and location of your medical records. You have the right know who is requesting medical information about you and have the opportunity to review any information prior to its being released from your doctor’s office. Insureds and claimants should discuss with their physicians how to handle doc-to-doc calls and frequent requests for information from insurers.
You have the right to a timely claim decisions. You have the right to expect your disability insurer will make every effort to render a claims decision within 45 days (ERISA claims) or that period of time indicated in the policy provisions. You have the right to be notified in writing every 30-45 days as to the reason why your claim decision is delayed. ERISA regulations require the insurance company keep you informed by sending “tolling letters” if the claim decision is not make within the 45-day period. Unresponsiveness is an unfair claims practice, as is deliberately delaying claims decisions with multiple requests for more and more information. All insureds and claimants have the right to timely claim decisions.
You have the right to request all communications in writing. In order to protect the integrity of the record you have the right to request to be free of phone calls from your insurers so that you are allowed the opportunity to think about your responses. This is particularly important to those who are taking pain or opiate medications. Insurance companies keep written records of every activity taken on the claim and insureds and claimants have the right to request all communications in writing to generate diary records of their own.
You have the right to a fair and objective claim review. You have the fiduciary right (ERISA) to expect your disability insurer will make every effort to consider ALL recommendations and opinions given to them by your primary care physicians, consultants, counselors, and any other specialist who is qualified to render an opinion concerning your ability to work. You have the right to expect the disability insurer will consider the experience and qualifications of your doctor as equal or better to those of its own in-house physicians, and to make fair and honest attempts to reconcile professional differences of opinion. All insureds and claimants have a right to expect that claims will not be targeted based on financial reserve values and will be reviewed in accordance with the unique circumstances of each claim.
You have the right to fair representation of facts. As the insured you have the right to a clear understanding as to the party or parties responsible for making the liability decision for your claim. You have the right to know who is authoring communications to you from your insurer, and the first and last names of all claims personnel, consultants, directors, and others who are offering medical or administrative opinions concerning the facts of your claim. You also have the expectation of receiving unbiased medical review and internal medical opinions that inherently will not cause you or others future harm. Insureds and claimants have a right to be told the truth, both verbally and in written communications.
You have the right to ask questions. As an individual outside of the specialty of the insurance industry, or understanding of that industry, you have the right to knowledge, explanation, definition, instruction and full understanding of the provisions of your policy without fear of loss of benefits. You have the right to ask questions concerning your claim as often as is necessary for your understanding of the facts without fear of retaliation, suspicion, or unfair investigation tactics. You also have the right to retain any third-party to assist you and to obtain information from any other resource as you feel is appropriate in defense of your claim.
You have the right to ethical conduct and “good faith and fair dealing. As an insured you have the right to expect your disability insurer, and its representative employees act in “good faith.” You have the right as an employee or policyholder to expect your insurance company creates and maintains a clearly defined disability claims review process which lends toward the fair, objective and timely, review of all claims submitted as part of its product business. You have the right to expect your insurance company have in place a process that routinely and consistently corrects flaws within the review process; recruits, trains and retains individuals qualified to review disability claims; and provides a forum for independent appeal processes.
You have the right of non-discrimination. All insured have the right to expect their insurance company not discriminate on the basis of benefit amount, self-reported or physical impairment, education, training or experience, occupation, age, sexual orientation, mental and nervous disorder, policyholder, geographical region, claim location, event, physician, claim duration, months of paid benefits, or any other target objective identified by management. You have the right of expectation that your claim will not be targeted by management for denial as a “block of business” due to any of the above. The right of non-discrimination also includes eliminating abuse of targeting and using “credibility issues” as sole cause for denial of claims.
You have the right of appeal. As an insured covered under the Employment Retirement Security Act of 1974 (ERISA) you have the right to a timely independent appeal review of your claim. For non-ERISA individual disability claims, you have the right to report discrepancies to your state authorities and to retain legal counsel, and request “reconsideration” of any denial decision. You also have the right to obtain copies of your Administrative Record or claim file if your claim has been denied; obtain counsel; and expect that all additional supporting documents submitted will be reviewed and considered.
You have the right to protect your health and body from disease. In today’s COVID environment, all insureds have the right to expect that their health and well-being will be protected through the IME process and that no action will be taken by insurers that deliberately places them in danger of contamination or contagion. Claimants have the right to challenge any actions that endangers their health and well-being.
This “Bill of Rights” was written by Linda Nee, a licensed Disability Claims Consultant. Although there is no law or regulation upholding these rights as an official document, the rights described herein are reasonable and should be expected from any disability insurer with a duty to uphold generally accepted industry standards to review claims objectively, and without bias or financial prejudice.