All insurance companies operate assuming most people who submit disability claims are “faking it” for the purposes of secondary gain. Although in reality, only 20% of claims are found to be fraudulent, insurers are always on the lookout for tell tale signs insureds aren’t being straight with them. This article might be longer than most, but it contains important information for my readers to know. So, bear with me.
All of the following are considered to be insurance “red flags”, meaning these situations will cause your claim to be subjected to greater scrutiny and investigation. Although this is not an all-inclusive list, it will give you an idea of what insurers are looking for to draw suspicion to your claim.
- Recent increase in benefits or indication of multiple coverage. Those insureds with multiple IDI policies might want to think about this. Buying multiple policies does NOT make your income more secure – it draws more risk.
- Failure to sign an Authorization or altering the Authorization. This is why most attorneys view “fighting” an Authorization to be a waste of time and a battle no one is likely to win.
- A long delay in submitting a claim. Again, IDI insureds are often the ones who wait a long time before submitting a claim.
- Claimant requests a quick decision on the claim, or offers to negotiate benefits.
- Claim forms submitted with demand letter by attorneys. Attorneys like to try and litigate claim even before there’s a case.
- An injury or illness coincides with a lay-off, plant closing, or job termination.
- Signature on Attending Physician’s Statement is similar to insureds’.
- Claimant provides inconsistent accounts of disability, or accident.
- Claimant is active in sports, or other strenuous activities.
- Claimant frequently cancels medical appointments, or erfuses to attend IMEs.
- Reported disability comes from subjective, or self-reported complaints such as back pain, strain, headache, vertigo, dizziness, depression or connectice tissue sickness or injury.
- Claimant is near retirement age, or in line for early retirement.
- Disability extends beyond the medical recovery length of time.
- Claim submits claim after a short time when a contestable period has expired.
- Difficulty in reaching the claimant at home, or claimant is reached at his office while disability is claimed.
- A pattern where several claimants are using the same doctor and/or attorney.
- Claimant has filed previous claims for other disabilities.
- Attending physician continually exxtends disability each time forms are sent.
- Claimant indicates an extraordinary kmowledge of claim procedures and insurance language and submits a claim with all documents needed to process claim with the initial proof of loss.
- Claimant is overly cooperative on the phone, but less so when furnishing documents.
- All documents are photocopied, few originals.
- Frequest calls to claims handler for status of claim. (I actually found this one documented in an insurance file. Despite my recommendations that insureds should not call their claims handlers, they often do, with disastrous results.)
- Constant threats to report the insurance company to the US Department of Labor or state Insurance Department.
- Claimant has a pager number, or answers the phone using a business greeting.
- Applicant wants to pay premium in cash.
In addition, many disability insurers also include the following “fraud” indicators:
- Late reporting.
- Actual, or anticipated economic hardships.
- Discrepancies between application statement and claim form statements.
- Claims just outside the contestability period.
- Job dissatisfaction, or recent career changes.
- Claims close to anticipated retirement.
- Unwitnessed accidents.
- Unlikely, or unusual scenarios.
- Late reporting.
- Buying multiple insurance policies.
“Red flags” challenge nearly every fact, figure and event provided to any disability insurance company. It is easy to see how an unknowiing claimant who is unhealthy and not feeling their best can quickly be seen as a malingerer attempting to obtaiin benefits for secondary gain. Any good, experienced disability claims specialist can take the above list of “red flags” and stack the deck against an insured sufficient to dely payment indefinately, or even deny the claim within a relatively short period of time. Surely, it must make one wonder whether any group LTD claimant really has any chance in hell of getting their benefits paid, especially without assistance.
It is really very unfortunate that claimants and insureds are unaware of the so-called “red flags” and continue to engage in behaviors that place claims in jeopardy.
Please feel free to contact me for assistance if you are being harassed by any of the above, or would like assistance in managing through the disability claims process. DCS has a 98% success rate with providing assistance to insureds and claimants who find their claims in jeopardy.
Please send an email to: lindanee.dcs@gmail.com or call 207-793-4593 to talk about how DCS can assist you in the future. My website is located at: http://www.disabilityclaimssolutions.com
