The title of this article refers to the actor Sam Worthington’s famous words, from the movie The Texas Killing Fields, “My pappy used to say, “Sometimes you git, and sometimes you git got”. While the euphemism from the Deep South might have brought a smile to our faces in the movie, it certainly can be thought of as applying to disability claims in certain circumstances.
Although not universally understood by all insureds, disability insurers can literally deny claims for little to no reason especially at this time of year. I refer to “profitability denials” as circumstantial since insurers will, of course, use every bit of information they can gather, even when at first glance it appears not to be relevant to the claims decision. Everything is important to an insurance company when it comes to reducing financial reserve and recording profit.
For example, insurers frequently use “traveling” as a circumstantial reason to deny claims. I have always advised my readers not to exceed R&Ls at any time. While traveling is likely to be argued by attorneys to the death as allowable, jurors will not be likely to decide in the Plaintiff’s favor when information is obtained from medical records showing travel to Chile, Brazil, and Mexico – worst yet, surveillance of extensive travel.
My recommendations NOT to engage in extensive travel, or activities that exceed R&Ls while on disability attempt to give “best practice” advice, but not everyone believes the experts until their “goose has been literally cooked.
Another example would be treating physicians who are contacted, but do not take the time to send rebuttal responses to insurers. Insurers always presume that if physicians do not respond to inquiries, that they agree with the insurance company. Suppose your physician went on a ski trip, or, is on maternity leave, and isn’t around to respond? Insurers will always allege a “non-response” is support for its own opinion that insureds can work.
Circumstantial denials are just as destructive as denials that cite pretty good evidence to support a denial decision. The difference is, that “circumstantial evidence” for disability claims is NOT factual, nor is it an accurate evaluation of claim circumstances even though the evidence seems quite persuasive at the time. It is tragic, when on appeal, that circumstantial evidence is also used to uphold denial decisions. It is far better for insureds to never “take the risk” of getting themselves in these types of predicaments.
Today due to the open availability of social media, use of circumstantial evidence to deny claim is a welcome opportunity allowing insurers to “find out information” about their insureds that can be distorted and misinterpreted. Opening the floodgate to “circumstances” rather than factual investigation is a major mistake one makes by pushing the envelope of R&Ls.
Finally, insureds cannot explain away circumstantial evidence particularly with statements such as, “I have good days and bad days. My traveling was on a good day.” Or, “I suffered for two weeks after my trip with a great deal of pain.” “My doctor recommends I get exercise.” Where is it documented? Forget it. Everyone, even healthy people have “good days and bad days, and if you can “travel” with pain, clearly you can work with pain. (Or so the insurance company will allege.)
So, “sometimes you git, and sometimes you git got”, particularly at the end of profitability periods. Taking risks with exceeding R&Ls clearly isn’t worth it when insurers use “circumstantial evidence” to deny claims just in time to make a few bucks off your claim.
