While so many people are trying to manage their own disability claims, I’m finding that what insureds DON’T KNOW is really starting to hurt them.
First on my list is in determining work capacity and knowing how to support it. Most of you are aware I spent nearly 10 years as a Lead claims handler, so this information is coming to you directly from the management of disability claims playbook.
Determination of whether someone gets paid or not depends on the official definition of disability from a Plan or policy. In most instances it is something like this…”you must be unable to perform the material and substantial duties of your own (or any other) occupation.” Insurance companies DO NOT just accept any fly by night proof of disability using medical restrictions and limitations. R&Ls ARE important, but what you don’t know going on behind the scenes can scrap a claim very quickly.
Shortly after a claim is presented for payment, the claims handler will call and ask to conduct a TPC, or person phone call. During that call, the rep will ask about your activities like doing laundry, gardening, voluntary activities etc. And, of course, those self-managing usually give the information freely, not understanding why it is asked for and how it will be used against them.
Let’s assume you told your claims handler you were able to do your own laundry and that it was located in your basement. You also told the rep you go for walks and are able to do your own grocery shopping. Starting with that…..let’s see….the ability to do laundry downstairs is the equalivent of at least 6 METS or “Light Work Capacity.” Walking and grocery shopping is another 5 METS…assumed to be Sedentary to Light Work Capacity. If your job is considered to be Sedentary or Light work yyou just gave yourself the ability to perform your own occupation.Did you know that?
A MET is a “metabolic equivalent of energy expended as compared to sitting in a chair.” This means that a person carrying laundry upstairs and downstairs will have to expend 6 times the energy they normally would be using if they were sitting in a chair. If your claim is “sedentary in nature” you get the picture? You have the ability to expend 6 times the metabolic energy required for you to do your job. NOT GOOD if you’re trying to support total disability.
Insurance companies have been using METS to determine functional capacity for a long time now. Anytime you walk/run on a treadmill, you are expending METS. What an opportunity for an insurance company who asks for FCEs (Functional Capacity Evaluations) to use the METS to determine work capacity! Walking a 15 min. mile, by the way, is the same as expending 10+ METS, or better than Light Work Capacity.
You probably also don’t know that insurance companies have Claims Benefit Manuals that instruct claims handlers on what to do and how to do it. I don’t know how they are managing that one today when the claims review process is so diversified that no one person knows what the others are doing. But, I’m pretty sure they haven’t let go of determining METS quite yet.
My point is, however, that most insureds have absolutely no idea what they’re doing or how to do it. Here are a few other things about the claims process that most insureds do not know.
- The outcome of any claim is determined within 30 minutes of review, and from that point forward the claim is managed toward that end unless YOU or someone else changes it. Do you know what that outcome is, and how to change it? Or, are you guessing?
- Claims are still targeted in accordance with benefit amount. Can you tell when, and how, your claim is targeted? Do you know how to “fix” a targeted claim?
- Do you understand the language in your Plan or Policy? How can you defend your claim if you don’t understand the Policy, or in fact, don’t even have a copy.
- Everything with disability insurance is how you position things. Do you know how to do that so that your claim is well supported?
Insureds today seem to think they can manage their own claims and continue to receive benefits. Some will, but many won’t. As soon as this post hits the Press, someone will write to me and tell me they’ve been managing their claim just fine. I don’t doubt that. But, look around you, there are probably hundreds who haven’t been that lucky. This post is for them.
