As a direct party, or participant, to a disability contract involving insurance coverage or income replacement, 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.
You have the right to full disclosure
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, but only when your claim is denied. This includes all administrative and chronological records, conversations, meetings, data base checks, electronic website information, field surveillance, website portal information, and any other data affecting your privacy as an individual. The insurance company, to deny your claim for benefits, must have relied upon disclosure information. Under ERISA regulations you have the right to receive a copy of your Plan and Administrative Record within 30 days of requesting it. If it has not been provided to you within the designated time frame, the insurance company may be fined $110 per day although there is no one overseeing the fine or enforcing it.
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. 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 being reviewed in a public forum and by whom. (Such as roundtables.) You also have the right to know the name and title of the person who will actually be making the decisions on your claim. Quite often, it is not the claims specialists who do this.
You have the right to a timely claim decision
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.
You have the right to a fair and objective claim review
You have the fiduciary right to expect your disability insurer will make every effort to consider ALL recommendations and opinions given to the insurer by your primary care physicians, consultants, counselors, and any other specialist who is qualified to render an opinion concerning your ability to work. (ERISA claims or industry standards if an Individual Disability policy) You have the right to expect the disability insurer will consider the experience and qualifications of your doctor as equal to those of its own in-house physicians, and to make fair and honest attempts to reconcile professional differences of opinion.
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 names of all employees, consultants, directors, and others who are offering medical or administrative opinions concerning the facts of your claim. You also have the expectation of unbiased medical review and internal medical opinions that inherently will not cause you or others future harm.
You have the right to withhold authorization of release of information that is overly broad; and to receive explanations as to why private information unrelated to your claim is requested.
Any individual has the right to retain privacy rights to information without fear of loss of benefits. It is your right not to sign Authorizations of Release which are overly broad, or, which allows the disability insurer to obtain information outside of what is required for a fair and objective review of your claim within the provisions of your policy. Many of the newer ERISA disability policies contain provisions which require you to sign an Authorization and cooperate with the insurance company or risk loss of benefits.
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 have the right to obtain and retain any additional assistance if needed.
You have the right to ethical conduct
As an insured you have the right to expect your disability insurer, and its representative employees act in “good faith and fair dealing.” 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 insureds have the right to expect their insurance company not discriminate on the basis of indemnity 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.
You have the right of appeal. (ERISA)
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.
Linda Nee, a Disability Claims Consultant, wrote this “Bill of Rights”. Although there is no law or regulation upholding these rights as an official document, the rights described therein 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.
