So much is written and said about what accountability insurance companies have to the disability Plan or IDI contract. However, claimants and insureds also have obligations to enter into the contract in good faith and fair dealing. Since most “obligations” are presumed, very few writers, attorneys and advocates mention them, even when claimants and insureds need a few good reminders.
Insureds can’t have it both ways. Insurers have their obligations under the Plan or contracts, but so do insureds. Therefore, Therefore, please consider the following:
Insureds and claimants are expected to do everything they can to get well and return to work. This means that, 1) Claimants are expected to remain in “regular and appropriate care” with their physicians, 2) Claimants are expected to take prescribed medications at the given dose, 3) Claimants are expected to provide update information when requested, 4) Claimants are expected to “cooperate” with the claims process but only as directed or contained within the Plan or policy contract, 5) Claimants promise to be truthful under penalty of fraud, 6) Claimants are expected to abide by reported medical restrictions and limitations, and 7) Claimants are expected to be proactive to return to work as soon as possible.
Insurance companies often have inappropriate ideas about what claimants should and should not do while on disability. For example, the most prejudiced and biased philosophy is that women should NOT get pregnant while on disability. The unwritten rule is that taking care of an infant is equal to at least “Light functional work capacity”, and if a woman can care for an infant, she can work.
Insurers also negatively view any insured who actively engages in “fertility treatments and procedures” to get pregnant while on disability. In addition, adopting a child while on disability is also a negative when seen from the insurer’s perspective.Finally, overusing alcohol or street drugs while on disability is a claim deniable offense.
Living with a non-working partner while receiving disability was seen so negatively by Prudential, that a woman’s claim was denied citing “supporting her boyfriend” as the reason for trying to remain on claim. (This was far-fetched to be sure!)
The truth is that insurance companies do not have control over the personal aspects of individuals’ lives. If you notice, accountabilities attributed to claimants are reasonable and in accordance with ERISA Plans or policy contracts. However, insurance companies use bias and company prejudice to also enforce what they consider are actions taken by claimants that DO NOT represent “trying to get back to work.”
Disability insurers also expect insureds and claimants to at least visually ACT disabled. As my readers and I both know, there are many disabilities that can’t be seen, such as pain. Insureds are visually seen as “acting normal”, or not acting as though he/she is in pain, or in fact that anything is wrong at all. Surveillance reports often include in writing, that “the insured looks normal, walked for 2 hours and there didn’t appear to be anything wrong.”
In fact, some insureds actually go to a gym and work out vigorously. Observed surveillance will make the case that the insured, “does not act disabled”, even when the gym workouts are recommended by treating physicians.
Therefore, while insureds are compliant with their own obligations to the claims process, insurers have concocted points of view derived from bias and prejudice. It’s best to keep all this in mind, when managing your own claim as it’s very easy to misstep your claim to an unsuccessful end.
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